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Summary of Background Data: 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. Questions/Purposes: (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? Patients and Methods: This prospective study involved a total of 60 patients (age group of 18 to 60 years) 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. Results: 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 11.93 min (range 8-15 min) against the mean duration of 6.87 min (range; 5 min to 9 min) in the other group (p < 0.001). Conclusion: Trimming the posterior femoral neck cortex after neck osteotomy results in better sagittal plane balance of uncemented straight femoral stem. Level of Evidence: III.
RESUMO
Introduction: To minimize the side effects of the central neuraxial blockade to obtain postoperative pain relief, there has been an increasing preference for targeting the peripheral structures in patients undergoing total hip arthroplasty (THA). Patients and Methods: This prospective study was performed between September 2019 and September 2021 and involved 30 patients that were randomized to two groups. One group (n = 15) received combined nerve block (CNB) [obturator nerve, nerve to quadratus femoris, superior gluteal nerve, and femoral nerve], while another group (n = 15) received periarticular infiltrative analgesia (PIA). All the patients were given the same volume and composition of the drug cocktail (20 ml 0.5% ropivacaine, 1 ml (100 mcg) dexmedetomidine, and 29 ml normal saline). Results: The patients in group CNB had a significantly lower visual analog score (VAS) at 6, 12, 18, 24, 30, 36, 42 and 48 h after surgery (p < 0.05). Patients in group CNB required fewer (p < 0.001) doses of the rescue analgesic (1.67 ± 0.90 doses) as compared to group PIA (3.53 ± 0.64 doses). Time to the first rescue analgesia was significantly longer (p = 0.01) in group CNB (6.71 ± 2.36 h) as compared to group PIA (4.80 ± 1.26 h). However, patients in group PIA had significantly faster sensory (p < 0.001) and motor recovery (p < 0.001) as compared to group CNB. It took significantly longer (p < 0.001) to administer the nerve block (16.87 ± 1.80 min) as compared to periarticular infiltration (6.53 ± 1.18 min). There were no complications in either group. Conclusion: CNB registered significant superiority over PIA with respect to postoperative pain relief and time to rescue analgesia. However, the time taken to administer CNB was significantly higher and the patients in the PIA group had early recovery in sensory and motor modalities. Level of Evidence: III (therapeutic).
RESUMO
The posterior approach to the humerus is an extensile approach, which provides excellent access to the distal aspect of the humerus. The approach is traditionally utilized for internal fixation of fractures of the distal third of the humerus, to perform sequestrectomy, and for radial nerve exploration. The radial nerve is susceptible to damage when utilizing this approach1-3. Hence, accurate localization of the radial nerve is required to aid in identification during dissection and to minimize the risk of palsy. Various anatomical landmarks have been described in the literature that can help locate the radial nerve intraoperatively. Description: The patient is anesthetized and placed in the lateral decubitus position with the elbow of the operative limb hanging freely over a bolster. A posterior midline incision centered over the fracture is made on the posterior aspect of the arm. The superficial and deep fascia are incised. The triceps aponeurosis is formed by the convergence and fusion of the lateral and long heads of the triceps. The most proximal confluence can be termed the "apex of the triceps aponeurosis." The radial nerve can be isolated approximately 2.5 cm proximal to the apex by developing an intramuscular plane. The remainder of the intramuscular dissection for plate fixation can then be performed safely without risking injury to the radial nerve. Alternatives: Numerous studies have established the relationship of the radial nerve to a fixed osseous point such as the medial epicondyle, lateral epicondyle, and angle of the acromion4-9. Additionally, the wide range of measurements of these anatomic relationships, as reported in various studies, makes it difficult for the operating surgeon to locate the radial nerve, especially in the setting of a fractured humeral shaft. For example, the reported distance of the radial nerve from the lateral epicondyle ranges from 6 to 16 cm and the distance from the angle of the acromion ranges from 10 to 19 cm. Even identification of the superficial branch of the radial nerve has been shown to help intraoperative localization of the radial nerve10. However, these studies have been conducted on cadavers with intact humeri, and their accuracy has not been demonstrated on the patients in the clinical milieu of trauma. Rationale: The described soft-tissue landmark, which lies approximately 2.5 cm proximal to the apex of the triceps aponeurosis, reliably locates the radial nerve intraoperatively11. It is based on the anatomical fact that the origins of the lateral head (oblique ridge corresponding to the lateral lip of the spiral groove) and long head (infraglenoid tubercle of the scapula) are well above fractures of the middle and distal thirds of the humerus. Hence, the relationship of the radial nerve to the soft point represented by the apex of the aponeurosis is not likely to be disturbed in the setting of fractures distal to it, in sharp contrast with previously described osseous landmarks. Expected Outcomes: Employing this anatomical understanding resulted in early localization of the radial nerve (within 6 ± 1.5 minutes of skin incision) and less blood loss (188 ± 13 mL)11. Patients are likely to retain their ability to perform active dorsiflexion of the wrist and fingers and have sensory preservation in the distribution of autonomous zone of the radial nerve after the procedure. Important Tips: The relationship of the radial nerve to the soft point represented by the apex of the aponeurosis is not likely to be disturbed in the setting of typical fractures distal to it; however, this may differ in cases of severely displaced or comminuted fractures, and the surgeon should be aware of this fact.The surgeon should remain careful to protect the vena comitans.
