Upper thoracic spondylitis tubercolosis treated by posterior approach only: A case report

INTRODUCTION AND IMPORTANCE

Mycobacterium tuberculosis (MTB) causes an infectious disease called tuberculosis which affects lung and other site of body. Spinal tuberculosis accounts for about half of all occurrences of skeletal tuberculosis. Patients with upper thoracic spinal TB are at an increased risk of severe spinal cord injury and kyphotic deformity, which may require surgery. Several treatment modalities include debridement, chemotherapy treatment, and decompression of the spinal twine and nerves.

CASE PRESENTATION

A female patient, 45 year old, came with inability to walk for 2 months. Pain had started for 1 year and it was getting worse until motor strength of both leg diminished. The patient was diagnosed spondylitis tuberculosis of thoracal 2nd ASIA B with myelopathy. We performed posterior instrumentation of Th1-Th3 continuous with decompression by laminectomy and transpedicular debridement. There was no neurological injury, wound infections, and other complications after the surgery. Outcome of the surgery was evaluated on 1 months after surgery.

CLINICAL DISCUSSION

The patient has good motor function one month following the operation. Without assistance, the patient could rise and take a few steps. Furthermore, the patient felt better overall and no longer had back discomfort, indicating that the surgery also had good results.

CONCLUSION

Posterior approach is feasible for internal fixation, debridement, and fusion in this case. It is minimal traumatic, good correction rate and prevents the progression of kyphosis. The spinal cord also can be decompressed with satisfactory result.

A comparison of three bone graft struts for interbody fusion using a posterior approach for lower lumbar spinal tuberculosis in adults: a midterm follow-up study

Background

This retrospective observational study was conducted to compare midterm outcomes of three bone graft struts for interbody fusion using a posterior approach in adults with lower lumbar spinal tuberculosis.

Methods

A total of 126 lower lumbar spinal tuberculosis patients were treated by one-stage posterior debridement, interbody fusion, and instrumentation. Forty-one patients (group A) were treated with autogenous bone graft for interbody fusion, 45 patients (group B) were treated with allogeneic bone grafting, and the remaining 40 (group C) patients were treated with titanium mesh cage. In addition, clinical and radiographic data were gathered and analyzed.

Results

At the final follow-up, all patients were completely cured. The operation period and intraoperative blood loss for groups B and C were significantly less than in group A (P = 0.000). Post-operation, neurological performance and quality of life were remarkably improved at the final follow-up. The preoperative lordosis angles of three groups were significantly improved, as evidenced by the values immediately after the operation or those at the final follow-up. The correction loss of the group C was lower than those of groups A and B (P = 0.000). All the patients obtained bone graft fusion, the fusion period of group B was longer than that of the other two groups (P = 0.000). No significant differences among the three groups in adjacent segment degeneration rates were found at the last visit (P = 0.922).

Conclusions

This midterm follow-up study established that one-stage posterior debridement, interbody fusion, and instrumentation, combined with medical therapy, can effectively treat lower lumbar spinal tuberculosis. In addition, the intervertebral titanium mesh cage bone graft can provide better outcomes with regard to maintaining lordosis and preventing collapse.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05539-8.

Comparison of clinical and radiological outcomes of local morselized bone grafts and structural iliac bone grafts in the treatment of lumbar tuberculosis with posterior-only surgery

Background

Many surgeons have reported results similar to those of anterior debridement and bone grafting in treating spinal tuberculosis in the lumbar region using only a posterior approach. However, there is still no consensus regarding bone graft methods. This study aims to compare the clinical and radiological outcomes of morselized versus structural iliac bone grafts in the treatment of lumbar tuberculosis via one-stage posterior surgery.

Methods

A retrospective study was performed with 82 patients with lumbar tuberculosis who had undergone posterior-only debridement, bone grafting, and instrumentation between January 2014 and June 2018. Morselized bone grafts were used in 43 patients, whereas structural iliac bone grafts were used in 39 patients. The clinical data and imaging results of the patients were compared between the two groups to evaluate the clinical effects of the two types of grafts.

Results

The operation time, blood loss and hospital stay values in the morselized bone group were significantly lower than those in the structural iliac bone group (p < 0.05). No significant differences were observed with respect to erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Cobb angle, or improvement of neurological function between the two groups. The VAS pain scores for low back and leg pain decreased significantly after the operation (p < 0.05). However, postoperatively, the VAS score was higher in the structural iliac bone group than in the morselized bone group, and there was no significant difference at the last follow-up between the two groups (p > 0.05). Bone fusion was achieved in 41 patients (95%) in the morselized bone group and 38 patients (97%) in the structural iliac bone group. There was no significant difference between the fusion rates of the two groups (p > 0.05).

Conclusion

The two graft techniques achieved comparable clinical outcomes in lumbar spinal tuberculosis treatment. However, the morselized bone graft was more beneficial in terms of reducing surgical trauma and postoperative complications.

A comparative of a single novice surgeon's direct anterior approach and posterior approach learning curves in total hip arthroplasty: a retrospective cohort study

INTRODUCTION

The purpose of the present study was to compare a novice surgeon's learning curves with the direct anterior approach and posterior approach in total hip arthroplasty.

METHODS

A consecutive series of 376 total hip arthroplasties performed from November 2014 to September 2019 in a level-one healthcare center by a single surgeon (V.B) were retrospectively studied. Demographic data, functional outcomes, and complications were collected and compared.

RESULTS

Within the ranks of the patients studied, we found differences between groups with respect to dislocation rate and length of stay; these were lower in the direct anterior approach (DAA) group. The approach was not associated with an increase in complications, but rather with a decrease in the rate of dislocations and better functional outcomes at 1-year follow-up. Operative time was initially higher with this approach, but equalized during the learning curve.

CONCLUSION

The DAA can be safe even in the early stages of a novice surgeon's learning curve. It does not present a higher complication rate than the posterior approach, either in infection rate or in periprosthetic fractures. However, the DAA may provide greater functionality, lower dislocation rate and a shorter hospital stay. It can also be concluded that after having performed a certain number of interventions, operative time for the DAA can be comparable to that of other approaches.

Anterolateral minimally invasive hip approach offered faster rehabilitation with lower complication rates compared to the minimally invasive posterior hip approach-a University clinic case control study of 120 cases

INTRODUCTION

The surgical approach used in total hip arthroplasty (THA) has been identified as a factor affecting the outcome. In our University Hospital, the posterior surgical approach is the gold standard. The Rottinger approach is an anterolateral approach which is truly minimally invasive, as it does not vertically cut any muscle fibers. The objective of this study was to determine the difference in surgical outcomes between the posterior hip approach and the Rottinger approach which was newly adopted at our Hospital.

METHODS

In a retrospective study, a total of 120 patients underwent THA; 60 patients using the Rottinger approach by the young consultant surgeon and another 60 patients using the standard posterior approach by the senior orthopaedic surgeon. Patients have been controlled for age, gender, and ASA grades. All preoperative demographic data showed no significant difference between the control and study groups. The following parameters were analyzed: incision length, duration of the surgery, intraoperative blood loss, WOMAC index, Harris Hip Score, range of motion at 3 and 12 months after surgery, time of quitting the crutches, and willingness for the contralateral hip arthroplasty.

RESULTS

WOMAC index, surgical time, and incision lengths have been without significant difference in both approaches. Intraoperative blood loss was significantly lower in the Rottinger group (CI:  - 10.903,  - 0.064). Harris Hip score was significantly higher (CI: 4.564, 12.973) in the Rottinger group at 3 months, but similar (CI:  - 3.484, 2.134) at 12 months follow-up. At 3 months, active flexion and extension were significantly higher in the Rottinger group (CI: 0.595, 8.239; 2.487, 4.480, respectively), and active abduction and passive adduction (CI:  - 5.662,  - 0.338;  - 6.290,  - 1.410, respectively) in the posterior approach group. Patients in the Rottinger approach group on average quit crutches 3 weeks earlier and had no postoperative dislocations compared to 2 dislocations in the control group.

CONCLUSION

The Rottinger approach offered faster rehabilitation with less need for crutches and with lower complication rates.

Scar Perception After Two Surgical Approaches for Total Hip Arthroplasty

Background

There is a paucity of literature examining patients’ and health-care providers’ perception of surgical scars after total hip arthroplasty (THA). This study examined perception of surgical scars after direct anterior (DAA) or posterior approach (PA) for THA using validated scar-assessment scales.

Material and methods

Seventy-five DAA and 75 PA THA patients underwent scar assessment using the Patient Observer Scar Assessment Scale (POSAS) and Stony Brook Scar Evaluation Scales. Mean age was different between the cohorts (DAA 67 vs PA 62 years, P = .01). All patients had subcuticular running closure, secured with skin adhesive glue. Mean time from THA to scar assessment was 3.1 and 3.6 years for the DAA and PA groups, respectively (P = .18).

Results

Scar opinion on the POSAS patient-reported scale was graded closer to normal skin more often for DAA than for PA patients (P = .03). More irregularities were graded for the DAA scars on the POSAS observer scale (P = .02) and the Stony Brook Scar Evaluation Scales (P = .04). Age did not predict scar opinion on any of the scales (P > .05). Female gender and a history of keloids predicted poorer scar appearance (P = .001 and P = .02). Overall scar appearance was rated as “good” in 93% of the DAA and 91% of the PA patients (P = .63).

Conclusion

Differences exist in DAA and PA scar perception based on validated scales. Future randomized trials in scar assessment may control for confounding variables such as age and gender, as well as potential biases when using scar assessment scales.

Modified posterior approach of the knee in patients with diffuse pigmented Villonodular synovitis: case series of a single Institution's experience

BACKGROUND

Diffuse pigmented villonodular synovitis (DPVNS) is a challenging tumor-like disorder that mainly occurs in the anterior aspect of the knee joint. The growth may sometimes extend to the posterior knee joint. Surgical excision is the mainstream treatment for DPVNS, and the posterior approach of tumor excision is adopted when the dominant tumor shows posterior extension. However, the optimal surgical approach over the posterior knee remains unknown.

METHODS

Patients with DPVNS of the knee joint who received the posterior approach of synovectomy from 1995 to 2019 were retrospectively reviewed to describe the modified separate posterior (SP) approaches, and evaluate the treatment outcomes in a case series of DPVNS knees. The results of the SP approach was also compared with those of traditional direct posterior (DP) approach. Postoperative functional outcomes were evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) standardized questionnaire and clinician-completed Musculoskeletal Tumor Society (MSTS) functional rating system at outpatient department.

RESULTS

A total of 20 DPVNS knees were included. Thirteen patients who received SP approaches were included in the SP group, while seven patients who received the DP approach were included in the DP group. The median follow-up times were 5.7 years (IQR, 2-8.8) in the SP group and 3 years (IQR, 2-5.3) in the DP group. Both groups showed satisfactory safety. The SP group presented higher postoperative mean WOMAC (91.23 ± 7.20) and mean MSTS (24.23 ± 2.68) than the DP group (mean WOMAC: 76.00 ± 16.57; mean MSTS: 22.43 ± 4.69). The Wilcoxon signed-rank test was use to compare preoperative and postoperative range of motion (ROM) for each group. The significant difference in SP group (p = 0.004) was found while p = 0.131 in DP group.

CONCLUSIONS

The SP approach provides an effective approach with satisfactory outcomes for the surgical treatment of DPVNS knees.

Surgical resection of intradural extramedullary tumors in the atlantoaxial spine via a posterior approach

BACKGROUND

The anatomical features of the atlantoaxial spine increase the difficulty of complete and safe removal of atlantoaxial intradural extramedullary (IDEM) tumors. Studies concerning surgical interventions via a posterior approach are limited.

AIM

To investigate the safety and efficacy of atlantoaxial IDEM tumor resection using a one-stage posterior approach.

METHODS

We retrospectively analyzed clinical databases for one-stage atlantoaxial IDEM tumor resection via a posterior approach between January 2008 and January 2018. The analyzed data included tumor position, histopathological type, pre- and post-operative Japanese Orthopedic Association (JOA) scores and Nurick grades, postoperative complication and recurrence status.

RESULTS

A total of 13 patients who underwent C1-C2 Laminectomy and/or unilateral facetectomy via the posterior approach were enrolled in the study. In all cases reviewed, total tumor resection and concomitant C1-C2 fusion were achieved. The average follow-up was 35.3 ± 6.9 mo (range, 26-49 mo). A statistically significant difference was noted between the preoperative JOA score (11.2 ± 1.1) and the score at the last final follow-up (15.6 ± 1.0) (P < 0.05). A statistically significant difference was noted between the preoperative Nurick grade (2.3 ± 0.9) and that at the last follow-up (1.2 ± 0.4) (P < 0.05). However, no statistically significant difference was noted between the preoperative and last follow-up C1-2 Cobb angle and C2-7 Cobb angle (P > 0.05). No mortalities, severe complications or tumor recurrence were observed during the follow-up period.

CONCLUSION

Total resection of atlantoaxial IDEM tumors is feasible and effective via a posterior approach. Surgical reconstruction should be considered to avoid iatrogenic kyphosis and improve spinal stability and overall clinical outcomes.

Clinical outcome and quality of life of lacrimal sac mucocele treated via endoscopic posterior approach

OBJECTIVE

Dacryocystorhinostomy (DCR) is the surgical treatment for lacrimal sac mucoceles (LSM), yet variants of the procedure are several. Since LSM causes bone remodeling and thinning, especially of the lacrimal bone, osteotomy at that site is reasonably the easiest. The aim of the study is to support treatment of LSM via a posterior DCR approach, in a large cohort of cases, and report patients' quality of life after the procedure with validated questionnaires.

METHODS

Single-center observational retrospective study on a specific methodology (endoscopic-DCR via posterior approach). Consecutive patients with LSM were enrolled in 2008-2020; CT scans were reviewed, bone thickness was measured bilaterally and compared. Resolution of mucocele, epiphora and infection were analyzed after 6-months. Patients were administered the Munk Score and Lacrimal Symptom Questionnaire (Lac-Q). Statistical analysis was done to compare bone thickness between the two sides; descriptive analysis of the questionnaires results was presented.

RESULTS

Forty-four patients with LSM were enrolled. The LSM side showed frontal process thickness of 4.00 ± 1.06 mm (vs 3.90 ± 1.03 on the unaffected side; p = 0.23) and a lacrimal bone of 0.32 ± 0.12 mm (vs 0.41 ± 0.12; p < 0.001). Resolution of infection was achieved in 97.4% cases, anatomical patency in 87.2%. After 5 years, 84.6% of patients reported no relevant epiphora (Munk score 0-1). Social impact (Lac-Q) due to lacrimal malfunctioning was still noted in 30.8% patients.

CONCLUSIONS

Adult LSM is a rare condition and DCR remains the mainstay of treatment. LSM physiopathology may support a preferred surgical choice via a posterior approach. Despite objective patency, some lacrimal way malfunctioning may be experienced in a minority of cases.

Surgical outcomes in children under 10 years old in the treatment of congenital scoliosis due to single nonincarcerated thoracolumbar hemivertebra: according to the age at surgery

Purpose

Hemivertebra is one of the common pathogenesis of congenital scoliosis. The timing of operation is undefined. Our study compared the surgical outcomes in children under age 10 years with scoliosis due to single nonincarcerated thoracolumbar hemivertebra according to the age at surgery.

Methods

From January 2009 to August 2017, we retrospectively investigated 34 consecutive cases of congenital scoliosis treated by posterior hemivertebra resection and fusion with pedicle screw fixation. All cases were divided into two groups according to the age at surgery and followed-up for at least 2 years, group 1 (≤ 5 years old), and group 2 (5 to 10 years old).

Results

The mean Cobb angle of the main curve was improved from 48.58° to 15.53° (68.05%) in group 1, and from 43.73° to 11.33° (75.43%) in group 2. The segmental curve was improved from 44.16° to 11.53° (74.64%) in group 1, and the segmental curve was consistent with the main curve in group 2. The mean segmental kyphosis was improved from 27.50° to 8.42° (67.40%) in group 1, and from 29.00° to 5.00° (84.73%) in group 2. Five patients developed distal adding-on, and four patients were found proximal junctional kyphosis during the follow-up.

Conclusion

Not all the deformities caused by single nonincarcerated thoracolumbar hemivertebra would progress greatly with the spinal growth. No significant statistical differences were found in the coronal and sagittal correction rate between the two groups. A limited delayed surgery after 5 years but before 10 years of age with close follow-up can achieve satisfied results.

Conundrum in surgical management of three-column injuries in sub-axial cervical spine: a systematic review and meta-analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

PURPOSE

Three-column injuries making the spine unstable require adequate fixation which can be achieved by anterior alone, posterior alone or combined anterior-posterior approach. There is no general consensus till date on a single best approach in sub-axial cervical spine trauma. This study comparing the three approaches is an attempt to establish a firmer guideline in this disputed topic.

MATERIAL AND METHODS

The protocol was registered with PROSPERO. PubMed, Embase and Google Scholar were searched for relevant literature. For each study, pre-defined data were extracted which included correction of kyphosis, loss of correction, hospital stay, operative time, blood loss during surgery as the outcome variables. Studies were also screened for the complications.

RESULTS

Eleven studies were evaluated for qualitative analysis and quantitative synthesis of the data in our review. The result demonstrated significant difference with most correction achieved in combined approach subgroup. Though no significant difference was found, the anterior group was having maximum loss of correction. Combined approach showed significantly more operative time and blood loss followed by posterior approach and then anterior approach alone. The improvement in VAS was significantly more in anterior subgroup when compared to combined approach.

CONCLUSION

Cervical alignment is best restored by combined approach compared to the other two. Anterior only approach showed more correction than posterior approach. However, there is no significant difference between all three approaches in loss of correction at long-term follow-up. Anterior only approach is superior to posterior and combined approach on basis of intraoperative and perioperative parameters.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Greater trochanteric pain after primary total hip replacement, comparing the anterior and posterior approach: A secondary analysis of a randomized trial

BACKGROUND

Greater trochanteric pain (GTP) after total hip replacement is a common cause of residual lateral hip pain, regardless of the approach used. The goal of our study was to evaluate GTP after a direct anterior approach (DAA) compared to a posterior approach (PA) as well as the clinical outcomes of both approaches and answer the following: 1) What is the incidence of trochanteric pain after primary THA with two different surgical approaches? 2) What is the functional outcome of patients with GTP? 3) What proportion of patients with GTP resort to peritrochanteric injections?

HYPOTHESIS

Our hypothesis is that GTP is present with both approaches but satisfaction is lower with the PA.

PATIENTS AND METHODS

A secondary analysis of a previously published clinical trial with 55 total hip arthroplasty patients randomized in one of two surgical approaches: 27 patients underwent the anterior modified Hueter approach, while the other group of 28 patients were operated using the posterior approach. Study outcomes were Modified Harris Hip Score (MHHS), satisfaction score, pain when lying on the affected side, and requiring an injection. Hip offset, femur lateralization and leg lengthening were measured before and after surgery.

RESULTS

Forty-five patients were available for complete follow-up at a mean of 62 months (range: 48-74). The incidence of GTP was higher in the posterior approach [PA: 6/21 (29%) vs DAA 4/24 (17%)) (p=0.3). Patients operated through a PA experienced more pain [5/21 (24%) of patients; VAS=mean 5.3] when lying on their operated side, compared to DAA patients [2/24 (8%) of patients; VAS=mean 2) (p=0.2)]. However, MHHS, patient satisfaction with surgery, radiological assessment for hip offset, femur lateralization or leg lengthening, and injections required were similar for both approaches. Overall, satisfaction and functional outcome with surgery was significantly lower in GTP patients, regardless of the approach.

CONCLUSIONS

GTP impacts patient satisfaction and functional outcome in total hip arthroplasty patients. PA patients reported more trochanteric pain than DAA patients, which affected their clinical outcome.

LEVEL OF EVIDENCE

III.

MRI assessment of piriformis-sparing posterior approach in total hip arthroplasty

INTRODUCTION

In total hip arthroplasty (THA), the posterior approach is the most common throughout the world. Dislocation is one of the main complications incurred, but the risk may be reduced by sparing posterior structures. Thus, piriformis-sparing posterior approaches (PSPA) were described, and satisfactory conservation of the muscle was reported. On the other hand, a recent cadaver study reported occult intrapelvic piriformis lesions in 91% of cases. In the light of this discordance, we performed pre- and postoperative MRI in THA by PSPA: 1) to assess the fatty infiltration of the piriformis induced by the approach, with particular attention to intrapelvic lesions; and 2) to assess fatty infiltration of the other periarticular muscles.

HYPOTHESIS

The piriformis muscle will show little fatty infiltration following PSPA.

MATERIALS AND METHODS

A continuous prospective single-surgeon series of THA by PSPA included 25 patients. MRI was performed preoperatively and at 3 months and 1 year postoperatively. Fatty infiltration was assessed on the Goutallier classification in all periarticular muscles.

RESULTS

Preoperative MRI was lacking in 4 patients, who were excluded from analysis; 21 patients with MRI were thus analyzed. In the piriformis muscle, there was no significant change in fatty infiltration between preoperative and 3-month (p=0.29) or 1-year (p=0.41) MRI. Two of the 21 patients (9.5%) showed grade 3 or 4 fatty infiltration at 1 year, compared to 0/21 (0%) preoperatively; both showed sacral avulsion of the piriformis. Significant differences between preoperative and 1-year MRI were found for the obturator internus and externus, with grade 3 or 4 infiltration at 1 year in 14 cases for the obturator internus (14/21: 66.7%), in 3/21 for the obturator externus (14.3%) and in 6/21 for the quadratus femoris (28.6%), compared to respectively 0/21 (0%), 0/21 (0%) and 3/21 (14.3%) preoperatively. There were no significant differences for any of the other periarticular muscles.

CONCLUSION

PSPA in THA ensured good conservation of the piriformis. There may, however, be rare and irreversible sacral lesions invisible intraoperatively.

LEVEL OF EVIDENCE

IV; prospective case series.

Posterior-only debridement, internal fixation, and interbody fusion using titanium mesh in the surgical treatment of thoracolumbar tuberculosis with spinal epidural abscess: a minimum 5-year follow-up

Objective

To investigate the clinical efficacy and feasibility of posterior-only debridement, internal fixation, and interbody fusion using titanium mesh in the surgical treatment of thoracolumbar tuberculosis (TB) with spinal epidural abscess.

Methods

From January 2008 to January 2014, a total of 45 patients (27 male and 18 female) were reviewed. The patients were diagnosed with thoracolumbar TB with spinal epidural abscess. The patients underwent posterior-only debridement, internal fixation, and interbody fusion using titanium mesh. Hence, we assessed the intraoperative and postoperative complications, disease recurrences, kyphosis deformity correction, and neurological improvement following the American Spinal Injury Association (ASIA). We used SPSS 22.0 for the statistical analyses. An independent Student’s t-test was used for the analysis of preoperative and postoperative continuous variables. The value of P (P < 0.05) was considered statistically significant.

Results

The mean age of patients was 37.76 ± 10.94 years (17–59 years). The mean follow-up time was 82.76 ± 12.56 months (60–128 months). The mean kyphosis Cobb angle preoperative was 29.36 ± 13.29° (5–55°) and postoperative was 3.58 ± 5.44° (− 6–13°), given the value of P (P < 0.001). According to the neurological score by the ASIA scale, there were 3 cases of grade B, 11 cases of grade C, 16 cases of grade D, and 15 cases of grade E preoperatively. The neurological score improved by 1 ~ 2 grades. All patients achieved pain relief and the VAS score significantly reduced at the last follow-up (P<0.05). While 1 patient had cerebrospinal fluid leakage, 1 had a neurological complication, 1 had delayed surgical wound healing, and 1 had a disease recurrence. No pseudoarthrosis or implant failure occurred in our patients. All patients achieved solid bone graft fusion.

Conclusion

For thoracolumbar TB patients with spinal epidural abscess, posterior-only debridement, internal fixation, and interbody fusion using titanium mesh are safe and effective surgical treatments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04797-2.

Risk factors of total blood loss in the posterior surgery for patients with thoracolumbar metastasis

Background

Blood loss in posterior surgery patients with thoracolumbar metastasis posed a significant challenge to surgeons. This study aimed to explore the risk factors of blood loss in posterior surgery for patients with thoracolumbar metastasis.

Methods

One hundred forty-two patients were retrospectively reviewed. Their baseline characteristics were recorded. The Gross equation was used to calculate blood loss on a surgical day. Multivariate linear regression was used to analyze the risk factors.

Results

Mean blood loss of 142 patients were 2055 ± 94 ml. Hypervascular primary tumor (kidney, thyroid and liver) (P = 0.017), wide or marginal excision (en-bloc: P = 0.001), metastasis at the lumbar spine (P = 0.033), and the presence of extraosseous tumor mass (P = 0.012) were independent risk factors of blood loss in the posterior surgery. Sub-analysis showed that wide or marginal excision (en-bloc: P < 0.001) and metastasis at lumbar spine (P = 0.007) were associated with blood loss for patients with non-hyper vascular primary tumors. Wide or marginal excision (piece-meal: P = 0.014) and the presence of an extraosseous tumor mass (P = 0.034) were associated with blood loss for patients with hypervascular primary tumors.

Conclusion

Hypervascular primary tumor (kidney, thyroid, and liver) was an independent risk factor of blood loss in the posterior surgery. The presence of extraosseous tumor mass and wide or marginal excision (piece-meal) were independent risk factors for patients with hypervascular primary tumors. Metastasis at the lumbar spine and wide or marginal excision (en-bloc) were independent risk factors for patients with non-hyper vascular primary tumors.

Medium-Term Follow-Up Outcomes of One-Stage Posterior Lumbosacral or Lumbopelvic Fixation in the Management of Lumbosacral Junction Tuberculosis in Adults

Objective

To evaluate the medium‐term outcomes of one‐stage posterior lumbosacral or lumbopelvic fixation treatment of lumbosacral junction tuberculosis in adults.

Methods

This retrospective study enrolled a total of 38 adult patients (24 males and 14 females) with an average age of 48.0 ± 13.0 years (range, 25–75 years) during the period from February 2008 to July 2015. All patients were treated by one‐stage posterior debridement, interbody fusion, lumbosacral or lumbopelvic fixation, and postural drainage. After pedicle screw or iliac screw fixation, a hemi‐laminectomy or laminectomy was performed on the severely damaged side of the lesion segment. Intervertebral bone grafting and intertransverse bone grafting were performed after clearing the focus of tuberculosis. All cases were followed up for at least 5 years. Intraoperative blood loss, operative time, erythrocyte sedimentation rate (ESR), pain intensity was assessed by visual analog scale (VAS) score; neurological function was assessed by Japanese Orthopaedic Association (JOA) score; quality of life was assessed by Oswestry Disability Index (ODI); functional outcome, lumbosacral angle, and fusion time were gathered and analyzed. All data expressed as mean ± standard deviation.

Results

During the 66.2 ± 4.4 months (range, 60–78 months) follow‐up, all patients achieved clinical cure without severe complications. The intraoperative blood loss was 726.3 ± 151.9 mL (range, 400–1100 mL) and the operative time was 137.6 ± 22.5 min (range, 110–200 min). The ESR decreased to normal levels within (11.8 ± 2.6 mm/h) 3 months postoperatively. The VAS score significantly decreased from 6.8 ± 1.1 preoperatively to 0.8 ± 0.7 at the final follow‐up (P < 0.01). The mean JOA improved from preoperative 18.5 ± 2.9 to 26.9 ± 1.1 at the last visit (P < 0.01). The mean ODI was 44.3 ± 6.7 and significantly decreased to 9.3 ± 1.9 at the final observation (P < 0.01). Patient‐reported outcomes as measured by Kirkaldy‐Willis criteria were excellent in 21 cases, good in 16 cases, and fair in one case; there were no poor outcomes. Lumbosacral angle increased from the preoperative values of 21.7° ± 1.8° to the postoperative values of 26.4° ± 1.4° (P < 0.01), with an angle loss of 1.2° ± 0.7° at the last follow‐up. Bone fusion occurred on average 12.8 ± 1.9 months (range, 9–15 months) after surgery. No nonunion, pseudarthrosis, loosening or fracture of instruments occurred at the last follow‐up.

Conclusion

One‐stage posterior debridement, interbody fusion, lumbosacral or lumbopelvic fixation, and postural drainage according to the severity of sacral destruction is an effective and highly safe procedure to treat lumbosacral junction tuberculosis in adults.

Multidisciplinary Management of Primary Sacral Tumors: A Tertiary Care Center's Experience and Literature Review

Sacral tumors are rare and can be benign or malignant. Their management is multifactorial and is based on the pathology, extent, and local and distant spread. Managing sacral tumors is challenging due to their proximity to visceral and neural structures. Surgical wide excision has been the standard of care for aggressive benign and malignant tumors. Our purpose was to evaluate the outcomes of a multimodal approach to managing primary sacral tumors in Sakra World Hospital, a tertiary spine care center in Bengaluru, India and perform a literature review to determine a workflow pathway. Our study was a retrospective review of patient records and included 15 patients with primary sacral tumors. Eleven surgically treated patients were evaluated clinically and radiologically and underwent biopsy before surgical excision by an all-posterior approach. A multidisciplinary approach that included intraoperative neural monitoring, plastic reconstruction, adjuvant chemotherapy, and radiotherapy was implemented whenever necessary. Sacral root preservation was attempted whenever feasible. Functional outcomes (based on the Visual Analog Scale [VAS] and Biagini scoring system) were analyzed along with disease control, with a minimum of 2 years of follow-up. The mean follow-up was 29±9.8 months. The mean VAS score significantly improved from 7.8±2.6 to 3.7±3.8 (p=0.026). Bowel function showed statistically significant improvement, from a mean score of 0.81±0.47 to 0.63±0.52 (p=0.026) at 2 years of follow-up. The mean pretreatment motor and bladder function scores were 0.53±0.31 and 0.74±0.44, respectively, improving to 0.48±0.33 and 0.68±0.56 at follow-up but without statistical significance. There was no significant loss of function, which is expected in radical sacral resections. In conclusion, primary sacral tumors require a multidisciplinary approach and management for optimal outcomes. A stand-alone posterior approach can be employed to treat most sacral lesions. En-bloc wide resection is the optimal treatment for primary malignant and aggressive benign tumors. Preservation of at least one functional S2 nerve root is imperative to preserve bowel and bladder function.

Delayed Femoral Artery Occlusion After Total Hip Arthroplasty via the Posterior Approach: A Single-Case Report From Thailand

Arterial injury after total hip arthroplasty is rare, but the consequences of this complication are serious and potentially life-threatening. Here, we report a case of delayed-onset common femoral artery occlusion after total hip arthroplasty that was performed via the posterior approach at Siriraj Hospital—Thailand’s largest university-based national tertiary referral center. Our case was successfully treated with arterial thromboembolectomy. We postulate that anterior retractor placement caused intimal injury to the vessel. Routine monitoring of postoperative vascular pulse is essential. Early detection and prompt vascular surgeon consultation are the important factors for preventing the potentially catastrophic consequences of this complication.

Durability of transosseous repair of posterior soft tissues after primary total hip arthroplasty: a prospective randomized controlled trial

PURPOSE

Posterior soft tissue repair is one of the methods for preventing dislocation after total hip arthroplasty (THA). This study aimed to evaluate durability of two separate suture materials in THA patients who underwent posterior soft tissue repair.

METHODS

42 THA patients were included in the study. The patients were randomly divided into two groups, where braided nonabsorbable suture was used in group A (n = 22), while braided absorbable suture was used in group B (n = 20). While repairing the posterior soft tissues, the piriformis and triceps coxae tendons together with the capsule were reattached to the greater trochanter via pull out sutures. Two hemoclips were attached as distance markers to both pull out sutures on the medial and lateal sides of the greater trochanter. Anteroposterior radiographs were taken one day, 15 days, 3 months and 6 months after operation. Distances between the hemoclips medial and lateral to the greater trochanter were measured on the radiographs, and the closest distances were recorded. The repair was considered a failure if the difference of distances between the first and any of the follow-up measurements exceeded 15 mm.

RESULTS

No statistically significant difference was observed between the groups. In both groups, elongation magnitudes in all time intervals were statistically significant while the results obtained from measurements taken 15 days after operation were more significant (p < 0.01). No dislocations were observed.

CONCLUSION

We conclude that for transosseous posterior soft tissue repair in THA, both absorbable and nonabsorbable sutures are similarly durable and can be routinely performed.

Restoring hip biomechanics during the learning curve of a novice surgeon: Direct anterior approach vs posterior approach

Introduction

It remains controversial whether the direct anterior approach (DAA) or the posterior approach (PA) allows better restoration of hip biomechanics after total hip arthroplasty (THA). Besides, it is not certain which approach is best for a novice surgeon to avoid implant malposition, neither during the learning curve nor once the curve plateau has been reached.

Methods

We performed a retrospective cohort study of THAs operated on between 2014 and 2019 by a single novice surgeon (DAA, n = 187; PA, n = 184). The surgeon used both approaches, and thus went through parallel learning curves.

Results

While the DAA presented a greater number of acetabular cup implantations within Lewinnek's "safe zone" for inclination (84.5% vs. 79.3%; p = 0.003), the PA returned superior results for anteversion (77.7% vs. 68.4%; p = 0.000). The PA showed a tendency to verticalize acetabular cups, while the DAA tended to antevert them. The DAA resulted in fewer patients with leg length discrepancy (3.2% vs. 8.2%, p = 0.041). No differences were found in stem coronal alignment or femoral offset.

Conclusion

Both approaches are safe and reliable for restoring hip biomechanics through THA surgery during the learning curve of a novice hip surgeon. Similar radiological outcomes are also seen once the surgeon has reached the learning curve plateau.

Do Patients With Higher Preoperative Functional Outcome Scores Preferentially Seek Direct Anterior Approach Total Hip Arthroplasty?

Background

There is focus on the direct anterior approach (DAA) for total hip arthroplasty because of perceived postoperative functional improvement. We compared baseline, short-term, and long-term outcomes between the DAA and the posterior approach focusing on baseline function.

Material and methods

Multivariate linear and logistic regression models were used to analyze prospective data on 1457 total hip arthroplasties comparing baseline characteristics, operative time, 90-day reoperation, length of stay (LOS), extended LOS (>3 days), and facility discharge. The Patient-Reported Outcome Measurement Information System-Global Health (PROMIS-10) was used to determine physical component score (PCS) and mental component score (MCS), with clinically significant improvement defined as >5 points. Adjusters included age, sex, race/ethnicity, year, Charlson Comorbidity Index, body mass index, alcohol, and tobacco use.

Results

DAA patients had higher preoperative MCS (DAA 50.4 vs posterior approach 47.4, P < .001), PCS (40.7 vs 38.5, P < .001), and postoperative PCS scores (48.9 vs 46.7, P < .001). There was no difference in mean PCS improvement (8.1 vs 8.2; P = .798) or clinically significant PCS change (P = .963). DAA was associated with shorter LOS by 0.49 days (95% confidence interval [CI] = 0.32-0.65, P < .001), lower odds of extended LOS (odds ratio = 0.33, 95% CI = 0.21-0.50, P < .001), and lower odds of facility discharge (odds ratio = 0.54, 95% CI = 0.37-0.79, P < .001). No difference in operative time (86 vs 87 minutes; P = .812) or 90-day reoperations (1 vs 1%; P = .347) was observed.

Conclusion

DAA patients presented with higher preoperative PCS and MCS scores, yet both groups experienced significant improvement. DAA was associated with decreased LOS and lower odds of extended LOS and facility discharge. There was no difference in operative time or reoperation.

Posterior Midline Approach for a C2 Schwannoma: 2-Dimensional Operative Video

C2 schwannomas are rare lesions that may develop in the spinal canal, in the area of the C2 ganglion situated posterior to the C1C2 articulation, in the extraspinal area or in a combination of these 3 sectors.1,2 The surgical removal of these lesions is delicate because of the intimate relationships the schwannomas develop with the V3 segment of the vertebral artery.  A variety of lateral, far-lateral, or extreme lateral approaches have been described in order to tackle these lesions. We use a posterior midline approach that takes advantage of the predominantly extradural development of C2 schwannomas. In this technique, the main step is the debulking of the posterior articular sector of the tumor, which is easily accessible through a midline posterior approach and necessitates minimal bone removal. In most cases, removal of the homolateral posterior arch of C1 is sufficient in order to create an adequate access. These maneuvers create the necessary space for dissecting both the intradural and extraspinal sectors of the schwannoma.  We present this technique through a case with a minimal intradural component exerting mainly a lateral compression of the spinal cord. The tumor was operated through the midline mini-invasive posterior approach with a favorable result. We demonstrate the surgical technique in video and discuss the nuances.

A Safe and Effective Posterior Intra-Articular Distraction Technique to Treat Congenital Atlantoaxial Dislocation Associated With Basilar Invagination: Case Series and Technical Nuances

BACKGROUND

The management of atlantoaxial dislocation (AAD) associated with basilar invagination (BI) is challenging, and traditional posterior-only approaches lack the ability to release the anterior soft tissue resulting in unsatisfactory reduction. Furthermore, vertebral artery anomalies and deformed anatomy increase surgical risks.

OBJECTIVE

To introduce a safe and efficient technique to reduce congenital AAD and BI through a single-stage posterior-only approach.

METHODS

A total of 65 patients with AAD and concomitant BI who had congenital osseous abnormalities were retrospectively analyzed. All patients had anterior soft tissue released through a posterior-only approach, followed by intra-facet cages implantation, cantilever correction, and instrumentation. Clinical results were measured using the Japanese Orthopedic Association (JOA) scale, and radiographic measurements included the atlanto-dental interval, the distance of odontoid tip above Chamberlain's line, clivus-canal angle (CCA), and syrinx length. Paired t-tests were used to compare preoperative and postoperative measurements.

RESULTS

The mean JOA score increased from 10.98 to 14.40 at 1-yr follow-up. Complete reduction of AAD and BI was achieved in 48 patients (73.8%). The mean CCA improved from 115° preoperatively to 129° postoperatively. Reduction of syrinx size was observed in 14 patients at 1 wk and in 35 patients 1 yr after surgery. All patients achieved bony fusion.

CONCLUSION

Posterior intra-articular distraction followed by cage implantation and cantilever correction can achieve complete reduction in most cases of congenitally anomalous AAD associated with BI.

Open Reduction on very late-presenting unreduced posterior elbow dislocation: Still promising treatment option

Background

Neglected dislocation of the elbow is associated with instability, pain, and limitation of elbow function. In developing countries, neglected dislocations of the elbow are quite common, and most patients initially go to local bonesetters, which only aggravates the problem.

Presentation of case

Two patients with a history of unreduced posterior elbow dislocation for more than 1 year and were treated by a traditional bonesetter were included in this case study. The first case was a 65-year-old female with a history of injury around her right elbow around 12 months before admission. The patient underwent open reduction with triceps lengthening and immobilization with plaster of paris for 3 weeks. The second case was a 53-year-old male with a history of injury caused by a fall on an outstretched hand around 18 months before admission. The patient underwent arthrolysis followed by triceps lengthening, internal fixation with transarticular k-wire, and immobilization with elbow slab for 3 weeks.

Discussion

To optimize treatment goals and patient function, various surgical approaches have been described for treating chronic elbow dislocations. The benefit of the V—Y triceps lengthening is to simplify the reduction procedure, especially in the elbow dislocations with greater chronicity. The downside of the V—Y lengthening is possible triceps weakness, delayed physiotherapy, and increased postsurgical pain. On the basis of this study, open reduction should remain a treatment option for patients regardless of age and chronicity of injury.

Conclusion

Operative treatment of late-presenting, unreduced elbow dislocation is effective in restoring the joint to a painless, stable, and functional limb.

•

Old unreduced posterior dislocation of the elbow is not uncommon in developing countries.

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The posterior elbow approach with V—Y triceps lengthening, arthrofibrolysis, open reduction, and fixation with k-wire is showing a promising outcome.

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Open reduction should remain a treatment option for patients with neglected posterior elbow dislocation, regardless of age and chronicity of injury.

Direct anterior approach has short-term functional benefit and higher resource requirements compared with the posterior approach in primary total hip arthroplasty : a meta-analysis of functional outcomes and cost

AIMS

It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs.

METHODS

This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding biases in the studies which were included. The mean cost and probability were used to determine the added costs of perioperative services.

RESULTS

The DAA group had significantly longer operating times (p < 0.001), reduced length of hospital stay by a mean of 13.4 hours (95% confidence interval (CI) 9.12 to 18; p < 0.001), and greater blood loss (p = 0.030). The DAA group had significantly better functional outcome at three (p < 0.001) and six weeks (p = 0.006) postoperatively according to the Harris Hip Score (HHS). However, there was no significant difference between the groups for the HHS at six to eight weeks (p = 0.230), 12 weeks (p = 0.470), six months (p = 0.740), and one year (p = 0.610), the 12-Item Short Form Survey (SF-12) physical score at six weeks (p = 0.580) and one year (p = 0.360), SF-12 mental score at six weeks (p = 0.170) and one year (p = 0.960), and University of California and Los Angeles (UCLA) activity scale at 12 weeks (p = 0.250). The mean non-stratified and stratified difference in costs for the operating theatre time and blood transfusion were $587.57 (95% CI 263.83 to 1,010.29) to $887.04 (95% CI 574.20 to 1,298.88) and $248.38 (95% CI 1,003.40 to 1,539.90) to $1,162.41 (95% CI 645.78 to 7,441.30), respectively, more for the DAA group. However, the mean differences in costs for the time in hospital were $218.23 and $192.05, respectively, less for the DAA group.

CONCLUSION

The use of the DAA, rather than the PA, in THA has earlier benefits for function and pain. However, these are short-lasting, with no significant differences seen at later intervals. In addition the limited benefits were obtained with higher cumulative costs for DAA. Cite this article: Bone Joint J 2021;103-B(6):1078-1087.