Early Outcome Comparison of the Posterior Approach and the Superior Approach for Primary Total Hip Arthroplasty

Background

The superior approach for total hip arthroplasty (THA) is a minimally invasive, tissue-sparing technique that may have clinical and economic benefits. The purpose of this study was to compare early outcomes between the posterior approach and the superior approach in primary THA. Our hypothesis was that the superior approach would have a noninferior length of stay (LOS), discharge destination, and blood loss compared with the posterior approach.

Methods

All primary THAs performed by a single surgeon at one institution were retrospectively reviewed over a 2-year period (2015-2017). There were 676 patients, 40.4% of whom underwent a posterior approach and 59.6% underwent a superior approach. LOS, discharge destination, blood loss, and operating room time were analyzed. Gender, body mass index, and American Society of Anesthesiologists status were recorded and controlled.

Results

The posterior approach was independently associated with an almost threefold higher risk of prolonged LOS (>2 days, P < .001) (odds ratio: 2.90, 95% confidence interval: 1.87-4.49; P < .001). The mean LOS for the superior approach was 1.71 days vs 2.17 days for the posterior group (P < .001). Fewer patients in the superior approach cohort were discharged to a rehabilitation facility (8.9% vs 17.9%, P < .001). The mean operative time was shorter in the superior group (91.8 vs 95.8, P = .001). There was no statistically significant difference in acute postoperative blood loss. There were no dislocations or reoperations in either group.

Conclusions

The superior approach to THA was associated with a significantly shorter length of hospital stay and lower rate of discharge to rehab than the posterior approach. This approach can be used as a safe, minimally invasive, and tissue-sparing variation of a standard posterior approach for THA and has promising early outcomes.

Posterior retroperitoneoscopic adrenalectomy: recommendations to implement this approach

INTRODUCTION

The posterior retroperitoneoscopic approach (PRA) is seldom used in our country to perform adrenalectomies, although it offers possible advantages over laparoscopic anterior or lateral access, according to some authors. The aim of this study was to identify those features that determine the most suitable cases to start the implementation of this technique.

METHODS

A prospective observational study was performed with a 50 patients cohort. All the cases were operated using the PRA. Sex, age, body mass index (BMI), operative time, left or right side, size and anatomopathological characteristics of the lesion, conversion rates, complications and hospital stay were analyzed.

RESULTS

25 (50%) women and 25 (50%) men underwent surgery, with a median operative time of 80 minutes (45-180). A significantly shorter operative time (p = 0.002) was observed in women and in adenomas (p = 0.002). However, no correlation was observed between surgical time and BMI, lesion side or lesion size. There were no conversions. The complication rate was 14%, and most of the complications were grade i in Clavien Dindo's Scale. Median hospital stay was two days.

CONCLUSIONS

Retroperitoneoscopic adrenalectomy by posterior approach is a safe and reproducible procedure, with very good outcomes. The most suitable cases to implement this technique would be female patients with adrenal adenomas.

Direct Anterior Approach Versus Posterolateral Approach in Total Hip Arthroplasty: A Systematic Review and Meta-analysis of Randomized Controlled Studies

Objective

To compare the early rehabilitation effects of total hip arthroplasty (THA) with the direct anterior approach (DAA) versus the posterior approach (PA).

Methods

We searched PubMed, Embase, Web of Science, the Cochrane Library, and Google databases from inception to June 2019 to select studies that compared the DAA and PA for THA. Only randomized controlled trials (RCT) were included. Two researchers independently screened studies for inclusion, extracted data, and assessed the methodological quality. A meta‐analysis was conducted using RevMan 5.3 software provided by Cochrane Assisted Network.

Results

A total of 932 patients underwent THA. There were 467 cases in group DAA and 465 cases in group PA. There was a significant difference in the incidence of lateral femoral cutaneous nerve injury between DAA and PA groups (RR = 38.97, 95% CI: 7.89–192.57, P < 0.05). DAA was associated with less pain compared with PA [WMD = −0.65, 95% CI (−0.91–0.38), P < 0.05]. There was no significant difference in operation time, hospitalization stay, and intraoperative bleeding volume. Moreover, in supplementary data, the number of acetabular prostheses in Lewinnek's safety zones in DAA was more than that in the PA group (RR = 1.20, 95% CI [1.04–1.39], P < 0.05), and the time of discontinuation of walking aids in the DAA group was earlier than that in the PA group (WMD = −11.05, 95% CI [−17.79–4.31], P < 0.05).

Conclusion

The DAA total hip arthroplasty has comparable results with PA, with earlier postoperative functional recovery, less postoperative pain scores, and higher incidence of lateral femoral cutaneous nerve injury. The results need to be validated by large‐sample, high‐quality RCT studies, and long‐term follow‐up of complications.

The efficacy of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis

Background

The bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis has not been explained in detail. We aimed to analyze the efficacy of bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis.

Methods

We treated 32 thoracic or thoracolumbar tuberculosis patients by one-stage posterior debridement, allograft bone graft using titanium mesh, posterior instrumentation, and fusion from May 2011 to September 2015. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were analyzed preoperatively, postoperatively, and at final follow-up. The Cobb angles were recorded to evaluate the kyphosis correction and the loss of correction. The bony fusion was evaluated by X-ray and computed tomography images, and the bony fusion classifications were recorded.

Results

All patients had pain relief. The erythrocyte sedimentation rate, C-response protein, and hepatorenal function were normal at final follow-up. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were improved in all the patients. All patients achieved bone fusion. Twenty-eight patients achieved complete fusion (Grade I), whereas only four patients achieved partial fusion (Grade II). The preoperative Cobb angle was 33.6 ± 9.3°. The Cobb angle was reduced to 10.6 ± 2.6° postoperatively and was found to be 11.4 ± 3.1° at the final follow-up. The mean angle correction was 23.0 ± 8.9°, and the correction rate was 66.2 ± 12.2%. The mean angle lost was 0.8 ± 0.9°, and the lost rate was 5.8 ± 5.4% at the final follow-up.

Conclusions

Allograft bone using titanium mesh in the posterior-only surgical treatment is effective for patients with thoracic and thoracolumbar spinal tuberculosis. It can correct kyphosis, and most patients can achieve complete bony fusion.

A posterior-only approach for ankylosing spondylitis (AS) with thoracolumbar pseudoarthrosis: a clinical retrospective study

Background

Surgical treatment has been recommended by most surgeons to treat pseudarthrosis in ankylosing spondylitis (AS). However, there is still some debate on the necessity of anterior fusion. There is very limited literature on the treatment and surgical outcomes of thoracolumbar pseudarthrosis in AS patients treated through a posterior-only approach.

Methods

From January 1, 2012 to December 31, 2017, a total of 42 cases diagnosed with thoracolumbar pseudarthrosis in AS patients with moderate kyphosis were included in this study. All of the patients received posterior-only kyphosis correction, internal fixation and fusion without anterior fusion, and underwent at least 2 years of follow-up. Clinical and radiographic results and complications were assessed.

Results

All of the patients were followed up for an average of 35.3 months (range, 24–48 months), and they achieved successful bone graft fusion at the pseudarthrosis sites. Satisfactory radiographic changes were achieved in these patients. The Cobb angles of global kyphosis (GK) were corrected from 53.2 ± 5.4 degrees preoperatively to 33.2 ± 4.3 degrees postoperatively, and to 36.1 ± 5.3 degrees at the latest follow-up. The Cobb angles of local kyphosis (LK) were corrected from 43.3 ± 4.6 degrees preoperatively to 26.8 ± 3.3 degrees postoperatively, and to 28.2 ± 3.6 degrees at the latest follow-up. The mean sagittal vertical axis (SVA) were corrected from 7.6 ± 4.2 cm preoperatively to 4.3 ± 2.1 cm postoperatively, and to 4.8 ± 2.3 cm at the latest follow-up. No serious neurological complication or deep wound infection was found in these 42 patients.

Conclusion

Posterior-only kyphosis correction and fixation without anterior fusion can achieve excellent bone fusion and satisfactory improvement in AS patients with thoracolumbar pseudarthrosis. This method may be a good choice for treating thoracolumbar pseudarthrosis in AS patients with moderate kyphosis.

Open repair with resection and reimplantation for popliteal artery aneurysm

Popliteal artery aneurysms are the most frequent type of peripheral arterial aneurysm and can be repaired by either open or endovascular techniques. An 81-year-old man presented with leg swelling and during duplex ultrasound examination was diagnosed a popliteal aneurysm. The transverse diameter was 3.6 × 4.5cm, length 2.8cm, one run-off vessel patent. The popliteal aneurysm was asymptomatic for clinical signs of limb ischaemia. We opted for an open surgical repair through a posterior approach. During dissection of the popliteal artery above and below the aneurysm, the two non-diseased popliteal extremities appeared to be very close, leading to the decision to perform an end-to-end anastomosis between the two arterial extremities. The patient was discharged after three days with no adverse events. Follow-up consisted of duplex ultrasound examination at one, three and six months, and then annually. At the six-month follow-up there was no restenosis at the anastomosis.

Clinical, functional and radiographic outcomes of primary total hip arthroplasty between direct anterior approach and posterior approach: a systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review and meta-analysis was to compare the direct anterior approach and posterior approach for primary total hip arthroplasty in terms of the clinical, functional and radiographic outcomes.

METHODS

We searched the PubMed and EMBASE databases and Cochrane Library from their inception to November 1, 2019. We searched for previously published articles and meta-analyses of randomized controlled trials.

RESULTS

A total of 7 randomized controlled trials with 600 participants met the inclusion criteria. Among these patients, 301 and 299 were included in the DAA and PA groups, respectively. The DAA was associated with a longer surgery by a mean duration of 13.74 min (95% CI 6.88 to 20.61, p < 0.0001, I2 = 93%). The postoperative early functional outcomes were significantly better in the DAA group than in the PA group, such as the Visual Analogue Scale (VAS) score at 1 day postoperatively (MD = -0.65, 95% CI - 0.91 to - 0.38, p < 0.00001, I2 = 0%), VAS score at 2 days postoperatively (MD = -0.67, 95% CI - 1.34 to - 0.01, p = 0.05, I2 = 88%) and Harris Hip Score (HHS) at 6 weeks postoperatively (MD = 6.05, 95% CI 1.14 to 10.95, p = 0.02, I2 = 52%). There was no significant difference between the DAA and PA groups in the length of the incision, hospital length of stay (LOS), blood loss, transfusion rates or complication rates. We found no significant difference between the two groups regarding late functional outcomes, such as the VAS score at 12 months postoperatively or the HHS scores at 3, 6, and 12 months postoperatively. A significant difference in the radiographic outcomes was not detected.

CONCLUSIONS

The DAA requires a longer surgery time than does the PA in primary total hip arthroplasty. The DAA yields better early functional recovery than does the PA. There was no significant difference between the two groups in terms of other clinical, complication-related, late functional or radiographic outcomes. The evidence on the superiority of the DAA is insufficient and needs to be studied further.

Giant intrathoracic ganglioneuroma with scoliosis treated by one-stage posterior resection and scoliosis correction: a case report

Spinal ganglioneuroma occurs mostly in the thoracic spine causing various manifestations including scoliosis that can be misdiagnosed as idiopathic scoliosis. Few reports exist in the literature on the diagnosis and management of scoliosis secondary to huge ganglioneuroma and usually staged treatment is preferred. In this report, we present a 17-year-old female patient presented with back pain, lower limbs numbness, spinal deformity, and shortness of breath. Plain X-rays showed a 50° right thoracic scoliotic curve. MRI and chest CT revealed a huge extra pulmonary mass shifting the mediastinum with intra spinal extension through the left neural foramina compressing the spinal cord. Percutaneous US guided needle biopsy confirmed the diagnosis of ganglioneuroma. One-stage posterior instrumented correction of scoliosis, spinal cord decompression, and excision of the whole mass from the mediastinum and the spine through posterior approach was done for the patient with smooth postoperative recovery. Chest CT scan was done 2 years after surgery and excluded any local recurrence.

Osteoporotic burst fracture-clinical, radiological and functional outcome of three-column reconstruction using single posterior approach (Instrumentation, Corpectomy, Arthroscope Assisted Transpedicular Decompression and Mesh Cage)

PURPOSE

To evaluate a novel effective procedure utilizing three-column reconstruction via a posterior approach with a technique that utilizes an arthroscope to visualize the anterior surface of the dura during decompression.

METHODS

A Prospective Study. 80 Osteoporotic vertebral burst fracture patients with similar demographic data managed by three-column reconstruction through single posterior approach surgery: Pedicle screw fixation, Corpectomy, Arthroscope Assisted Transpedicular Decompression (AATD) and Fusion (Mesh Cage + Bone grafting). Preoperative and postoperative clinical parameters (Visual Analog Score VAS, swestry Disability Index ODI, neurlogy, radiological parameters and surgical variables were recorded analysed.

RESULTS

No significant differences in demographic data. Significant improvement was noted in VAS (pre-operative, 7.90 ±0.60; final follow-up 2.90 ± 0.54) and ODI (preoperative, 77.10 ± 6.96; final follow-up 21.30 ± 6.70). Neurological improvement was noted in 74 patients (Frankel grade E) while six patients remained non-ambulatory (Frankel grade C). Significant improvement was noted in local kyphosis angle (preoperative, 22.14 ± 2.60; postoperative, 10.40 ± 1.40) with a 10% loss of correction (2.5 ± 0.90) at final follow-up. Implant failure in two patients and proximal junctional failure in two patients managed with revision surgery. No iatrogenic dural or nerve injury.

CONCLUSIONS

Osteoporotic Burst fracture can be managed with single posterior surgery, three-column reconstruction with mesh cage. It provides a significant improvement in clinical, radiological and functional outcomes. The arthroscope can improve a surgeon's operative field and magnification thereby ensuring complete decompression without injuring the dura or spinal cord.

The posterior cervical transdural approach for retro-odontoid mass pseudotumor resection: report of three cases and discussion of the current literature

OBJECTIVE

The treatment of a retro-odontoid pseudotumor mass associated with severe spinal cord compression is challenging due to the complex regional anatomy. Here, we present an attractive treatment option involving a single-stage posterior transdural microsurgical resection followed by instrumented cervical reconstruction.

METHODS

We describe three patients presenting with clinical signs of cervical myelopathy and an imaging finding of mucoid and fibrous soft or semi-soft retro-odontoid pseudotumor mass with significant spinal cord compression at the C1/C2 level. Given the severity of the symptoms, surgical decompression was planned and fusion was necessitated by the severe degenerative osteoarthritis seen at the C1/C2 level with signs of instability. Using a standard posterior approach to the spine, a suboccipital decompression by craniectomy and laminectomy of C1, C2 and C3 was performed. The masses were visualized and confirmed with ultrasound imaging, and intraoperative neurosurgical monitoring was applied. The dura was then opened from the level of C0-C2. Exiting C2-C3 nerve roots were identified and protected throughout the procedure, and the dentate ligament was cut to facilitate access. Incision of the anterior dura provided easy access to the lesion for resection without any spinal cord retraction. Multiple intraoperative samples were sent to pathology for tissue diagnosis. The dura was closed with sutures and an overlay of fibrin sealant with collagen matrix sponge. The fusion procedures were performed using a standard occipital cervical plate and screws technique with contoured titanium rods.

CONCLUSIONS

The posterior cervical transdural approach is a safe alternative procedure for mucoid and fibrous soft or semi-soft retro-odontoid pseudotumor mass removal. Preoperative CT scan can evaluate tissue characteristics and distinguish between a soft or ossified mass in front of the spinal cord. Local anatomical conditions facilitate less bleeding and adhesions, together with less spinal cord traction, in the intradural space. Cranio-cervical and suboccipital stabilization can be easily and safely performed with this exposure.

Technique for Open Posterior Cervical Foraminotomy: 2-Dimensional Operative Video

Foraminal stenosis is an important cause of cervical radiculopathy, which can be treated with an anterior or posterior approach, depending on a number of factors. These include the etiology of the foraminal stenosis, individual patient risk factors, and surgeon preference. We provide a step-by-step technique guide for performing an open posterior cervical foraminotomy on a 33-yr-old male with a history of left-sided pain radiating down the medial aspect of his left arm and left triceps weakness. Magnetic resonance imaging demonstrated a left-sided C6-7 disc herniation causing foraminal stenosis. Guidance on positioning, relevant anatomy, and appropriately planning the extent of bony decompression is also provided in this video. The patient, who consented to the recording of this surgical video, tolerated the procedure without complication, and upon follow-up had a significant improvement in his symptoms.

Thoracolumbar Vertebral Column Resection With Rectangular Endplate Cages Through a Posterior Approach: Surgical Techniques and Early Postoperative Outcomes

BACKGROUND

Thoracolumbar pathology can result in compression of neural elements, instability, and deformity. Circumferential decompression with anterior column reconstruction is often required to restore biomechanical stability and minimize the risk of implant failure.

OBJECTIVE

To assess the safety and viability of wide-footprint rectangular cages for vertebral column resection (VCR).

METHODS

We performed VCR with wide-footprint rectangular endplate cages, which were designed for transthoracic or retroperitoneal approaches. We present our technique using a single-stage posterior approach.

RESULTS

A total of 45 patients underwent VCR with rectangular endplate cages. Mean age was 58 yr. Diagnoses included 23 tumors (51%), 14 infections (31%), and 8 deformities (18%). VCRs were performed in 10 upper thoracic, 17 middle thoracic, 14 lower thoracic, and 4 lumbar levels. Twenty-four cases involved a single level VCR (53%) with 18 two-level (40%) and 3 three-level (7%) VCRs. Average procedure duration was 264 min with mean estimated blood loss of 1900 ml. Neurological outcomes were stable in 27 cases (60%), improved in 16 (36%), and worse in 2 (4%). There were 7 medical and 7 surgical complications in 11 patients. There were significant decreases in postoperative thoracic kyphosis (47° vs 35°, P = .022) and regional kyphosis (34° vs 10°, P < .001). There were 2 cases of cage subsidence due to intraoperative endplate violation, neither of which progressed on CT scan at 14 and 35 mo.

CONCLUSION

Posterior VCR with rectangular footprint cages is safe and feasible. This provides improved biomechanical stability without the morbidity of a lateral transthoracic or retroperitoneal approach.

Modified osteotomy of posterolateral overhanging part of the trochanter via posterior approach for hip arthroplasty: an anatomical study

Backgroud

The osteotomy of the posterolateral overhanging part (PLOP) of the greater trochanter via posterior approach has been used for the hip arthroplasty for decades with good results. However, the osteotomy method remains undefined and the precise adjacent structures around PLOP have not been reported. The purpose of this study was to present a modified PLOP osteotomy approach and perform a detailed study of the topographic and surgical anatomy of the PLOP.

Methods

The peri-PLOP soft tissue and the bony parameters were measured using 10 cadavers with 20 hips and 20 skeletal hip specimens, respectively.

Results

A 1.8-cm vertical osteotomy did not jeopardize the femoral neck, and a 1.8-cm wide bone block did not damage the insertions of the short external rotators. The average distances between the most distal branch of the superior gluteal nerve/artery and the 1.8-cm point of the greater trochanter were 5.70 ± 0.66 cm and 6.33 ± 0.56 cm, respectively.

Conclusion

For osteotomy of the PLOP, we suggested that the width of the upper side from the lateral to medial greater trochanter should be 1.8 cm, depth of vertical osteotomy should be 1.8 cm, and length of the posterior edge should be 4 cm. Obturator externus tendon should be kept within the bone block of osteotomy. The proximal extension of the gluteus medius muscle split should be limited to 5.5 cm at the 1.8 cm-point of the greater trochanter.

Level of evidence

Prospective comparative study Level II.

Thoracolumbar burst fractures associated with incomplete neurological deficit in patients under the age of 40: Is the posterior approach enough? Surgical treatment and results in a case series of 10 patients with a minimum follow-up of 2 years

INTRODUCTION

Surgical management of thoracolumbar burst fractures is controversial. While the goals of surgical treatment are well accepted (i.e., fracture reduction and stabilization, neural elements decompression, and segmental angular deformity correction), the choice of the best surgical approach (i.e., posterior vs. anterior vs. combined approach) remains controversial. Several studies have debated the advantages of each surgical approach but there is no definitive evidence available to date, particularly in young adult patients. The aim of this study was to assess whether posterior approach alone can be a valid surgical treatment for patient under the age of 40 affected by thoracolumbar burst fractures and incomplete neurological deficits.

MATERIAL AND METHODS

A total of 10 consecutive patients affected by thoracolumbar burst fractures associated with incomplete neurological deficits treated at our institution from January 2015 to February 2017 were included in our study. All patients were under the age of 40 at the time of injury and underwent decompression and stabilization using the posterior surgical approach alone. Demographics, clinical, and radiographic parameters were recorded preoperatively, postoperatively and at the latest available follow-up. The minimum follow-up was set at 2 years post-operatively.

RESULTS

The mean operative time was 303.6 min (range, 138-486). Average blood loss was 756 mL (range, 440-2100). Nine out of ten patients returned to a normal neurological status after surgery while 1 patient showed some improvement but did not recover completely. Segmental kyphotic deformity improved from a mean of 21.8° before surgery to 14.8° at the time of the last follow-up. The anterior and posterior wall height of the fractured vertebra was restored with an average of 4 mm. The Visual Analogue Scale score reported an improvement from the mean preoperative value of 7.92 to 1.24 at the last follow-up; 8 out of 10 patients resumed physical activity while all of them returned to work.

CONCLUSIONS

A single posterior surgical approach is an acceptable option in terms of clinical, radiological and functional outcomes at 2 years follow-up in patients under the age of 40 presenting with a thoracolumbar burst fracture and neurological deficit.

Posterior versus direct anterior approach in revision hip arthroplasty using Kerboull-type plate

Introduction: The purpose of this study was to investigate revision with a Kerboull-type plate through the posterior approach (PA) and direct anterior approach (DAA) and compare the clinical outcome.

Subjects and methods: Fifty-four patients (56 hip joints) underwent revision surgery in which acetabular reconstruction was performed concomitantly using the Kerboull-type plate and allogeneic bone. Revision surgery through DAA was performed in 21 hip joints and these were compared with 34 hip joints treated through PA. There was no significant difference in the patient demographics between the DAA and PA.

Results: There was no significant difference between the operative times in the DAA and PA groups (203.2 ± 43.5 and 211.7 ± 41.8 min). There was a significant difference between the intraoperative blood loss in the DAA and PA groups (503.9 ± 223.7 mL and 703.8 ± 329.6 mL, respectively, p < 0.05). There was no significant difference between the modified Harris Hip Score in the DAA and the PA groups. The loosening of the acetabular component was observed in four cases (11.8%) in the PA group. In the DAA and PA groups, the 5-year survival rates were 100 and 85.7%, respectively. Recurrent dislocation of the hip was observed in six cases (one case in the DAA group (4.8%) and five cases in the PA group (14.7%)).

Conclusions: It was verified that the difference in the surgical approach of acetabular reconstruction concomitantly using the Kerboull-type plate and allogeneic bone graft influenced the postoperative outcome.

Anterior versus posterior approach in the management of AO Type B1 & B2 traumatic thoracolumbar fractures: A level 1 trauma centre study

The authors perform a retrospective trauma registry study to compare clinical, surgical and radiographical variables between anterior and posterior approaches in the management of AO Type B1 and B2 traumatic thoracolumbar fractures. Consecutive patients with surgically-managed AO Type B1 and B2 thoracolumbar fractures were included. Baseline demographics, surgical outcomes (including duration of surgery, postoperative morbidity etc.), neurological outcomes and radiographical outcomes (Cobb angle, Gardner angle) were compared between the anterior and posterior approaches. A total of 108 patients (anterior: n = 25, posterior: n = 83) were included. There were no significant between-group differences in baseline demographics and co-morbidities. Duration of surgery was longer in the anterior compared to posterior group (251 ± 91 min vs. 175 ± 69 min respectively, p < 0.00003). At six-months post-surgery, there was a trend towards improvement of at least one AIS grade in the posterior compared to the anterior group (85.7% vs. 33.3% respectively, p = 0.08). Postoperative complication profile showed no difference between approaches. The posterior approach resulted in better sagittal correction (Cobb angle; anterior: +1.05 ± 8.61 deg, posterior: -3.87 ± 9.88 deg, p = 0.03) and smaller loss of correction at 6-months post-surgery (Cobb angle; anterior: 8.36 ± 9.47 deg, posterior: 4.88 ± 6.62 deg, p = 0.048). This is the first study investigating surgical approach in flexion-distraction thoracolumbar fractures. Besides a shorter operative duration, the posterior approach seems to portend more favourable radiological correction at 6 months when compared to the anterior approach. Given the inherent selection bias of this study, definitive recommendations regarding the anterior versus posterior approach cannot be made. Further well-defined, prospective studies are necessary.

Tailored Posterior-Only Approach for C2 Vertebral Body Lesions: Our Surgical Experience in 10 Patients

BACKGROUND

C2 vertebral body (axis) lesions are often approached anteriorly and combined with posterior stabilization of the craniovertebral junction (CVJ). The anterior approach has its limitations. A posterolateral corridor is an alternative access to the C2 body lesions, and this alone may suffice in selected cases. We describe our experience with C2 body lesions, dealt primarily through a posterior approach, and propose an algorithm in the management of such cases.

METHODS

Ten patients with axis lesions were operated through a midline posterior approach followed by posterior stabilization of the CVJ in the same sitting. Their preoperative and follow-up clinico-radiologic details were reviewed.

RESULTS

The lesions included aneurysmal bone cysts (n = 2), fibrous dysplasia (n = 2), chordoma (n = 2), Ewing sarcoma (n = 1), metastases (n = 1), post-traumatic malunion (n = 1), and post-inflammatory deformity (n = 1). All patients presented with worsening neck pain. Five also had spastic quadriparesis. There were no perioperative complications. All showed clinical improvement at follow-up. Only 2 patients (chordoma: n = 1; aneurysmal bone cyst: n = 1) required an additional anterior procedure.

CONCLUSIONS

Adequate debulking or total excision of lesion, neural decompression, and stabilization of the CVJ for axis body lesions can be achieved through a single midline posterior approach in most cases. If required, an anterior approach may be later added depending on the final histopathology.

[Reduction of the atlantoaxial dislocation associated with basilar invagination through single-stage posterior approach: using Xuanwu occipital-cervical reduction surgical suite]

Objective: To examine the effect of posterior reduction in atlantoaxial dislocation (AAD) associated with basilar invagination(BI) using Xuanwu occipital-cervical fusion system in single stage. Methods: Thirty-seven AAD accompanied with BI cases treated at Department of Neurosurgery, Xuanwu Hospital, Capital Medical Universiy and the Second Hospital of Hebei Medical University were retrospective analyzed. There were 15 males and 22 females with age of (42.3±12.3)years (range: 18-69 yars). All the cases had congenital osseous abnormalities, such as assimilation of atlas and abnormal cervical fusion. Anterior tissue was released through posterior route followed by cage implantation into facet joint and occipital-cervical fixation with cantilever technique. The clinical results were evaluated using Japanese Orthopedic Association scale(JOA) and the main radiological measurements including anterior atlantodental interval (ADI),the distance of odontoid tip above Chamberlain line,clivus-canal angle (CCA) and the length of syrinx were collected.The preoperative and postoperative JOA score and radiological measurements were compared by paired t-test. Results: The mean JOA score of the patients increased from 10.5 to 14.4 at the one-year follow-up(t=14.3,P=0.00).Complete reduction of AAD and BI was achieved in 34 patients.The mean clivus-canal angle improved from 118.0 degrees preoperative to 143.7 degrees postoperative(t=6.2,P=0.00). Shrinkage of the syrinx was observed 1 week after surgery in 24 patients, and 6 months in 31 patients. Twenty-eight patients achieved bone fusion 6 months after surgery. All the patients achieved bone fusion 12 months after surgery. One-side vertebral artery occlusion was diagnosed in 1 case postoperatively for transient dizziness, and relieved in 2 weeks. Two patients developed moderate neck pain after surgery, and relieved in 1 month. No implant failure, spacer subsidence or infection was observed. Conclusions: The treatment of AAD associated with BI using Xuanwu occipital-cervical fusion system from posterior approach in single stage is effective and safe. Cage implantation intraarticularly and fixation with cantilever technique achieve complete reduction in most cases.

Clinical Efficacy of Three Surgical Approaches for the Treatment of Cervicothoracic Tuberculosis: A Multicenter Retrospective Study

Objective

To evaluate the efficacy of three surgical approaches for the treatment of cervicothoracic tuberculosis.

Methods

This is a multicenter retrospective study. We analyzed 74 patients with cervicothoracic tuberculosis who were treated in six institutions between January 2000 and January 2015. There were 37 male and 37 female patients, with an average age of 24 years (range, 5–62 years). The operative method was selected according to the indications. A total of 33 patients underwent one‐stage anterior surgery (group A); 16 underwent a combined anterior and posterior surgery (group B) and 25 underwent one‐stage posterior surgery (group C). Clinical outcomes, laboratory indexes, and radiological results were analyzed.

Results

All cases were followed up for approximately 36–96 months post‐surgery (average, 39 months). At the last follow‐up, patients in all three groups had achieved bone fusion, with pain relief and neurological recovery. No major vessel and nerve injuries were found during the operation. There were significant differences before and after treatment for visual analogue scale (VAS), neck disability index (NDI), and Japanese Orthopedic Association (JOA) score (P < 0.001). Three surgical strategies significantly improved kyphosis (P < 0.001).

Conclusion

The choice of operation for cervicothoracic tuberculosis should be selected based on the pathological changes, scope, and general physical condition of the patient. The indication for a posterior approach is narrow and it should be used selectively. The combined anterior and posterior approach involved a longer operating time, larger blood loss, and greater trauma, and also required a higher level of surgical skill. Therefore, the indications for this approach should be strictly controlled. Anterior approach surgery for the treatment of cervicothoracic tuberculosis showed excellent efficacy and fewer complications.

The Value and Limitation of Cervical Traction in the Evaluation of the Reducibility of Atlantoaxial Dislocation and Basilar Invagination Using the Intraoperative O-Arm

OBJECTIVE

To assess the value and limitation of cervical traction in the evaluation of the reducibility of atlantoaxial dislocation (AAD) and basilar invagination (BI) using the intraoperative O-arm.

METHODS

A total of 22 patients with hyperextensive, irreducible AAD were included. The cervical traction test under general anesthesia was performed, and the degree of reduction was evaluated using the O-arm before the operation started. The traction effects both vertically and horizontally were evaluated. All cases then underwent modified direct posterior reduction and fixation. Clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scale. Radiologic measurements included the anterior atlantodental interval, the distance of odontoid tip above Chamberlain line, and the clivus-canal angle. Magnetic resonance imaging signal changes, size of syringomyelia, and the space ventral to medulla also were used to evaluate the postoperative reduction result.

RESULTS

After the cervical traction test, 7 patients achieved incomplete reduction, 5 achieved only vertical reduction, 6 achieved only horizontal reduction, and 4 achieved complete reduction in both horizontal and vertical orientations as assessed by the O-arm. All patients underwent a direct reduction technique. The mean JOA score increased from 11.1 to 14.5. Complete reduction of AAD and BI were achieved in 19 patients (86.4%), with partial reduction achieved in 3 (13.6%). Sufficient cerebrospinal fluid space anterior to the medulla with improved JOA score was achieved in the 3 partially reduced patients.

CONCLUSIONS

With the innovations of direct posterior reduction techniques, cervical traction under anesthesia may not sufficiently predict the reducibility of BI and AAD. Cervical traction still plays an important role during the direct posterior reduction procedure.

Anterior versus posterior approach in traumatic thoracolumbar burst fractures deemed for surgical management: Systematic review and meta-analysis

Uncertainties remain regarding the optimal surgical approach in the treatment of traumatic thoracolumbar burst fractures. We aim to compare the surgical, radiological and functional outcomes in anterior versus posterior approaches in patients with traumatic thoracolumbar burst fractures deemed for surgical management. A systematic review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Qualitative analysis and where suitable, meta-analysis were performed to compute pooled estimates of the differences between anterior and posterior approaches. A total of six studies (three observational, one prospective non-randomized trial, two randomized controlled trials) were included. There were no cases of postoperative neurological decline. Meta-analysis demonstrates a longer duration (Mean Difference (MD) + 81.68, 95% CI 39.20 to 123.16, p < 0.001) and increased estimated blood loss (MD + 426.27, 95% CI 119.84 to 732.70, p = 0.006) for the anterior approach. No difference between approaches was found regarding length of hospital stay, late postoperative kyphotic angle, construct failure rate, instrumentation revision rate, rate of return to work, and total hospital charges. Limitations include the small number of, and heterogeneity across studies. Given the similarities in neurological, radiological and functional outcomes between the two approaches, the longer duration and estimated blood loss in the anterior approach should be a point of consideration when selecting the surgical approach. There is an urgent need for contemporary, high quality research in this area.

Hip hemiarthroplasty for senile femoral neck fractures: Minimally invasive SuperPath approach versus traditional posterior approach

BACKGROUND

The supercapsular percutaneously-assisted total hip (SuperPATH®) approach was created by combining the percutaneous preparation of the acetabulum using the percutaneously-assisted total hip (PATH), femoral reaming, and broaching of superior capsulotomy (SuperCap) approach. This technique reported a low complication rate, excellent gait kinematics, low transfusion rate, a shorter length of hospital stay, and a high proportion of discharge from the hospital. As minimally invasive SuperPath approach is designed for both trauma and end-stage degenerative joint disease, we investigated if this technique and standard surgical tools can replace artificial femoral head in elderly patients with femoral neck fracture. We also tested if it has advantages over the traditional posterior approach.

METHODS

A prospective study was performed in 100 cases of eligible femoral neck fractures from May 01, 2015 to October 31, 2016. They were randomly divided into SuperPath and traditional group. The outcomes were evaluated using preoperative index, intraoperative data, and postoperative function data.

RESULTS

No significant difference was detected in the operation time between the two groups. Compared with the traditional group, SuperPath group had smaller incision length, less intraoperative bleeding, lower transfusion rate, and a shorter starting time of weight-bearing activity. Harris Hip Score, Barthel Index, and VAS for pain-level scores in the SuperPath group at 1-week follow-up intervals were significantly lower than the conventional group, but not significantly different at 3-month and 2-year follow-up post-operation.

CONCLUSIONS

SuperPath approach for artificial femoral head replacement can reduce surgical injury due to smaller size of incision and accelerate weight-bearing activities post-operation to treat senile femoral neck fractures compared with traditional posterior approach surgeries.

Technique of Minimally Invasive Cervical Foraminotomy

BACKGROUND

Posterior cervical foraminotomy is a long utilized and commonly performed procedure, but has been supplanted in many cases by anterior procedures. With the advent of minimally invasive techniques, posterior foraminotomy may again deserve a prominent place in the treatment of cervical foraminal stenosis.

OBJECTIVE

To report in detail a successfully utilized minimally invasive technique and the results in a large series of patients, by a single author.

METHODS

The technique is described and illustrated in detail. A retrospective review of the use of this technique in a large series is reported.

RESULTS

Precise details of the technique are described with specific attention to complication avoidance. In over 360 cases, there have been no nerve root injuries other than idiopathic C5 palsies, no wound infections, and a single durotomy that required no specific treatment.

CONCLUSION

Minimally invasive posterior cervical foraminotomy is a well-tolerated and effective procedure which can be performed with minimal complications when attention to detail is maintained.

Degenerative Cervical Myelopathy: A 7-Letter Coding System That Supports Decision-Making for the Surgical Approach

Objective

To validate with a prospective study a decision-supporting coding system for the surgical approach for multilevel degenerative cervical myelopathy.

Methods

Ten cases were presented on an internet platform, including clinical and imaging data. A single-approach (G1), a choice between 2 (G2), or 3 approaches (G3) were options. Senior and junior spine surgeons analyzed 7 parameters: location and extension of the compression of the spinal cord, C-spine alignment and instability, general morbidity and bone diseases, and K-line and multilevel corpectomy. For each parameter, an anterior, posterior, or combined approach was suggested. The most frequent letter or the last letter (if C) of the resulting 7-letter code (7LC) suggested the surgical approach. Each surgeon performed 2 reads per case within 8 weeks.

Results

G1: Interrater reliability between junior surgeons improved from the first read (κ = 0.40) to the second (κ = 0.76, p < 0.001) but did not change between senior surgeons (κ = 0.85). The intrarater reliability was similar for junior (κ = 0.78) and senior (κ = 0.71) surgeons. G2: Junior/senior surgeons agreed completely (58%/62%), partially (24%/23%), or did not agree (18%/15%) with the 7LC choice. G3: junior/senior surgeons agreed completely (50%/50%) or partially (50%/50%) with the 7LC choice.

Conclusion

The 7LC showed good overall reliability. Junior surgeons went through a learning curve and converged to senior surgeons in the second read. The 7LC helps less experienced surgeons to analyze, in a structured manner, the relevant clinical and imaging parameters influencing the choice of the surgical approach, rather than simply pointing out the only correct one.

Comparative cohort study of the SuperPath approach and the conventional posterior approach in primary cementless hip replacement surgery

BACKGROUND AND OBJECTIVES

There is no current consensus on the most suitable hip approach. However, there is a trend to reduce damage to soft tissue, which may have an influence on early outcomes. The SuperPath approach accesses the capsule maintaining integrity of the external rotators. The purpose of this study was to compare the SuperPath approach with the conventional posterior approach, in terms of early outcomes and radiological results.

MATERIAL AND METHODS

A cohort of 30 patients operated using the SuperPath approach was prospectively matched for age, gender, body mass index and hip function with 60 patients operated using a conventional posterior approach. Clinical evaluation was performed by the Harris score, Merle d'Aubigné score, reduced Western Ontario and McMasters Universities (WOMAC), Short-Form 12 (SF12), IHOT-ADV and IHOT-12 questionnaires. Radiological evaluation was also performed.

RESULTS

Preoperatively, no significant differences were detected between cohorts. Skin-to-skin operation time and blood loss was higher in the SuperPath cohort. Length of stay was similar between cohorts. Clinical evaluation improved significantly from the preoperative values to the 1-year follow-up. At 3 months the SuperPath cohort showed better results for IHOT-12, and at 12 months for SF. Radiologically, there were no differences between cohorts.

CONCLUSION

This prospective randomized study reveals that the learning curve for the SuperPath approach provides similar outcomes to the conventional posterior approach within the first year after surgery. The Superpath approach was associated with longer skin-to-skin operation time, and greater blood loss.