Debate on direct-anterior vs posterior approach for hip hemiarthroplasty: The authors’ insights

We read and discussed the study entitled “Complication rates after direct anterior vs posterior approach for Hip Hemiarthroplasty in elderly individuals with femoral neck fractures” with great interest. The authors have done justice to the topic of comparison of anterior and posterior surgical approaches for bipolar hemiarthroplasty which has been an everlasting debate in the existing literature. However, there are certain aspects of this study that need clarification from the authors.

Improved patient reported outcomes with the direct anterior approach versus the posterior approach for total hip arthroplasty in the early post-operative period

BACKGROUND

Patients undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA) may experience faster recovery but may also have better baseline health than those who undergo THA with the posterior approach (PA). This study aimed to compare patient-reported outcome measures (PROMs) between the DAA and PA while controlling for baseline factors.

METHODS

This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform following THA. The primary outcomes were HOOS JR and EQ-5D-5L through 1 year and change from baseline. Longitudinal regression models were created to control for baseline characteristics and investigate the impact of surgical approach on PROMs.

RESULTS

Of 1364 THAs evaluated, 731 (53.6%) were female, and 840 (61.6%) used the PA. Patients in the PA group were of similar age but had higher body mass index and comorbidity scores. Pre-operative HOOS JR and EQ-5D-5L were comparable, but higher post-operatively in the DAA group through 6 months (p = 0.03 and p = 0.005). At 1 year post-operatively, HOOS JR and EQ-5D-5L did not vary between groups (p = 0.48 and p = 0.56), nor did changes from baseline (p = 0.47 and p = 0.11). After controlling baseline characteristics, DAA was significantly associated with higher average HOOS JR through 6 months (p = 0.03) and EQ-5D-5L through 3 months (p  = 0.005), but not at 12 months (p = 0.89 and p = 0.56).

CONCLUSION

THA patients undergoing DAA demonstrate earlier improvements in HOOS JR and EQ-5D-5L. However, these differences may not be clinically significant and are not evident at 1-year post-operative. Patient selection and surgeon training may continue to affect outcomes by surgical approach.

Anatomical study of the modified direct posterior gluteal splitting approach for acetabular fractures

BACKGROUND

In this study, we investigated the area that can be addressed with an approach in which the skin incision is made directly above the dorsal column with Thiel cadaveric specimens.

METHODS

Six Thiel cadaveric specimens were prepared. A skin incision was made directly above the dorsal column. The accessible proximal end from the proximal part of the greater sciatic notch to the gluteal ridge and the accessible distal end of the ischium were marked with a flat chisel. A molded 8-hole reconstruction plate was placed from the base of the ischium toward the gluteal ridge and fixed with 3 screws proximally and 2 screws distally. The length of the skin incision and the distance from each reference point on the bone to the reachable markings were assessed after the muscles were removed.

RESULTS

Mean skin incision length was 9.3 ± 0.7 (range, 8.0-10.0) cm. In 3 of 6 cases, proximal screws were inserted through different spaces between muscle fibers. In all cases, we were able to reach at least the greater sciatic notch, the gluteal ridge at the level of superior border of the acetabulum, and the base of the ischial tuberosity. In all cases, an 8-hole plate could be placed from the gluteal ridge to the base of the ischium. There were no superior gluteal artery or sciatic nerve injuries in any of the cases.

CONCLUSION

We anatomically investigated the area that can be addressed with an approach in which the skin incision was made directly above the dorsal column. In all cases, we were able to access the areas needed to reduce the fracture and place the plates necessary to stabilize the fracture through a 9.3 ± 0.7 cm skin incision. This approach can be a useful minimally invasive posterior approach for acetabular fractures.

A comparative study between open pre-peritoneal approach versus laparoscopic trans-abdominal pre-peritoneal approach in recurrent inguinal hernia repair: a prospective cohort study

BACKGROUND

The repair of recurrent inguinal hernias after prosthetic mesh repair is challenging due to the technical complexity and complications associated with it. As well as the increased risk of recurrence due to weakened tissues and distorted anatomy. The Posterior Pre-Peritoneal Approach yields significantly better results than the anterior approach due to its distance from previously scarred tissue.

OBJECTIVE

To compare the open pre-peritoneal approach and Laparoscopic trans-abdominal pre-peritoneal approach in the management of recurrent inguinal hernia which was previously managed through an open anterior approach regarding their intra-operative time, the postoperative outcomes in the form of hematoma, wound infection and finally the recurrence within 1-year follow-up.

PATIENTS AND METHODS

The current study is a prospective cohort study, a single-center trial conducted from June 2021 to June 2022 in the general surgery department in Ain Shams University Hospitals, which included 74 patients presented with recurrent inguinal hernia who had previous open anterior approach 68(91.8%) males and 6(8.1%) females including a 1-year follow-up postoperative.

RESULTS

There were 74 patients in our study with 37 patients in each group. Group (I) underwent an open pre-peritoneal approach and group (II) underwent a Laparoscopic trans-abdominal pre-peritoneal approach. The mean age of the group (I) is 39.51 with a standard deviation of  ± 3.49. While in group (II) the mean age is 39.37 with standard deviation  ± 3.44 (p = 0.881). From the included 74 patients 67(91.8%) were males and 6(8.1%) were females. As regards the co-morbidities, in group (I) 17(45.9%) patients have no co-morbidities, 11(29.7%) patients have diabetes mellitus, 6(16.2%) patients have hypertension, and 3(8.1%) patients have diabetes and hypertension. Andin group (II) 26(70.3%) patients have no co-morbidities, 6(16.2%) patients have diabetes mellitus, 3(8.1%) patients have hypertension, and 2(5.4%) patients have diabetes and hypertension (p = 0.207). Regarding intra-operative time, the mean time in minutes in the group (I) is 63.33 with a standard deviation of  ± 11.95. While in group (II) the mean time in minutes is 81.21 with a standard deviation of  ± 18.03 (p = 0.015). The postoperative outcomes were assessed for 1-year follow-up in the form of hematoma, wound infection, and recurrence within 1 year. Regarding the hematoma occurred in 4(10.8%) patients in group (I). While in 2(5.4%) patients in group (II) (p = 0.674). The wound infection was found in 5(13.5%) patients in group(I) and zero patients in group (II) (p = 0.021). Finally, we followed up with the patients for about 1 year to detect the recurrence. Which was found in 3(8.1%) patients in group (I) and 1(2.7%) patient in group (II) (p = 0.615).

CONCLUSION

The results of this study demonstrate that both the laparoscopic approach and the open posterior approach are effective for recurrent inguinal hernia following anterior approach mesh hernioplasty, with comparable results. Laparoscopy has been associated with a lower rate of recurrence and overall complications compared to open technique, however, it is difficult to draw definitive conclusions about the preferred option due to its lengthy learning curve and difficulty to perform. Furthermore, the results of this study confirm the previously reported positive results of the posterior pre-peritoneal for recurrent inguinal hernia, particularly when performed by experienced surgeons. Therefore, further prospective randomized population-based trials are necessary to better assess the decision-making for recurrent hernia management and the impact of specialization in abdominal wall surgery in terms of recurrence and complications.

Posterior intra-articular distraction technique to treat pediatric atlantoaxial instability

PURPOSE

Surgical treatment for atlantoaxial instability in pediatric patients is challenging. We report our experience with posterior intra-articular distraction technique in treating this disorder.

METHODS

This is a retrospective descriptive study which included 15 patients of atlantoaxial instability whose age was less than 16 years at the time of clinical presentation. All patients underwent anterior soft tissue released through a posterior-only approach, followed by intra-facet cage implantation, cantilever correction, and instrumentation. Clinical results were measured using the Japanese Orthopedic Association (JOA) scale and radiographic measurements including the atlantodental interval (ADI), posterior atlantodental interval (pADI), the distance of odontoid tip above Chamberlain's line, clivuscanal angle (CCA), and triangular area (TA) of craniovertebral junction.

RESULTS

The follow-up period ranged from 18 to 72 months, with an average of 41.2 ± 15.2 months. The JOA score increased from 13.6 ± 2.3 to 16.6 ± 0.8. ADI decreased from 4.31 ± 2.37 to 1.85 ± 1.09 mm, and TA decreased from 261.96 ± 107.99 to 197.12 ± 72.37 mm2. pADI increased from 12.89 ± 3.52 to 18.25 ± 3.89 mm, and CCA improved from 132.19 ± 16.34 to 144.35 ± 13.91°. All changes in measurements showed statistically significant. There were no evidence of surgery-related complications or iatrogenic secondary cervical deformity during follow-up. Radiological evaluation showed satisfactory corrections and bony fusions of C1-2 facet joint in all cases.

CONCLUSION

Posterior intra-articular distraction followed by cage implantation and cantilever correction can be one of the safe and effective ways to solve atlantoaxial instability in pediatric patients.

Open reduction and internal fixation of crescent fracture-dislocation: anterior or posterior approach?

INTRODUCTION

To date, the approach that prevails in the open reduction and internal fixation of crescent fracture-dislocations (CFD) remains unknown. This study aimed to compare the outcomes of CFD treated via the anterior or posterior approach.

MATERIALS AND METHODS

Data from 64 cases of CFDs openly reduced through an anterior (group A, n = 31) or a posterior (group B, n = 33) approach were retrospectively analyzed. Functional results, reduction quality, residual displacements in the axial and coronal planes, pelvic asymmetry deformity, and correlations between Day's classification were compared. Complications and fracture union were also recorded. All patients were followed up for at least 12 months.

RESULTS

The functional scores were similar between the two groups, and all fractures achieved good or excellent reduction postoperatively. In the coronal plane, the excellent/good ratio in group B was higher than in group A. The mean residual displacement in the coronal plane was significantly higher in group A than in group B, with group A showing greater displacement in both planes for Day I fractures and in the coronal plane for Day II fractures. The residual displacement in both planes for Day III fractures was comparable between the groups. The pelvic asymmetry deformity was equal between the two groups and among the different Day's fracture types.

CONCLUSIONS

Open reduction and internal fixation of CFDs obtained satisfactory outcomes through an anterior or posterior approach. The posterior approach achieved a better sacroiliac joint reduction. The optimal indication for the posterior approach was a Day I fracture, followed by a Day II fracture. No correlation was found between the surgical approach and reduction quality in Day III fractures.

Comparison of transoral anterior Jefferson-fracture reduction plate and posterior screw-rod fixation in C1-ring osteosynthesis for unstable atlas fractures

Objective

To compare the clinical outcomes of transoral anterior Jefferson fracture reduction plate (JeRP) and posterior screw rod (PSR) surgery for unstable atlas fractures via C1-ring osteosynthesis.

Methods

From June 2009 to June 2022, 49 consecutive patients with unstable atlas fractures were treated by transoral anterior JeRP fixation (JeRP group) or PSR fixation (PSR group) and followed up at our hospital; 30 males and 19 females were included. The visual analogue scale (VAS) score, neck disability index (NDI), distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMDs), Redlund-Johnell value, postoperative complications, and fracture healing rate were retrospectively collected and statistically analyzed.

Results

Compared with that in the PSR group, the bleeding volume in the JeRP group was lower, and the length of hospital stay was longer. The VAS scores and NDIs of both groups were significantly improved after surgery. The postoperative DAAF and DPAF were significantly smaller after surgery in both groups. Compared with the significantly shorter DPAF in the PSR group, the JeRP group had a smaller DAAF, shorter LMDs and larger Redlund-Johnell value postoperatively and at the final follow-up. The fracture healing rate at 3 months after surgery was significantly greater in the JeRP group (P<0.05).

Conclusion

Both C1-ring osteosynthesis procedures for treating unstable atlas fractures yield satisfactory clinical outcomes. Transoral anterior JeRP fixation is more effective than PSR fixation for holistic fracture reduction and short-term fracture healing, but the hospital stay is longer.

Delayed presentation of lower cervical facet dislocations: What to learn from past reports?

Delayed presentation of lower cervical facet dislocations is uncommon, and there is no standardized way to approach these neglected injuries. The literature on neglected lower cervical facet dislocations is limited to case reports and few retrospective studies. This justifies the need for a comprehensive review of this condition. Our purpose was to elaborate a review on the epidemiology, clinical and radiological presentation, and treatment techniques and approach to these neglected injuries. Middle-aged adults from 30 to 50 represent 73.8% of reported cases, and most of them are males (72.0%). The most affected level is C5-C6 (43.0%). While most delays are due to missed injuries (52.1%) and ineffective non-operative treatment (36.2%), the other reason for delay is negligence in seeking medical care (11.7%). Patients present with variable degrees of neurological deficit, persistent neck pain, and neck stiffness. Reported approaches and techniques to reduce and stabilize these injuries are highly variable and depend on the surgeon's judgment, experience, and preference. Fibrotic tissues and bony fusion around the dislocated facet joint contribute to the reduction challenge, and 77.0% of closed reduction attempts fail. Anterior and posterior approaches to the cervical spine are used selectively or in combination for surgical release, reduction, and stabilization. Despite the lack of standardized treatment guidelines and different approaches, most of the authors reported improvement in pain, balance, and neurology post-surgery. Starting with the posterior surgical approach aims to achieve reduction compared to the anterior approach which largely aims at spinal decompression. Given the existing controversies, the need for quality prospective studies to determine the best treatment approach for lower cervical facet dislocations presenting with delay is evident.

Complication rates after direct anterior vs posterior approach for hip hemiarthroplasty in elderly individuals with femoral neck fractures

BACKGROUND

Dislocation rates after hemiarthroplasty reportedly vary from 1% to 17%. This serious complication is associated with increased morbidity and mortality rates. Approaches to this surgery are still debated, with no consensus regarding the superiority of any single approach.

AIM

To compare early postoperative complications after implementing the direct anterior and posterior approaches (PL) for hip hemiarthroplasty after femoral neck fractures.

METHODS

This is a comparative, retrospective, single-center cohort study conducted at a university hospital. Between March 2008 and December 2018, 273 patients (a total of 280 hips) underwent bipolar hemiarthroplasties (n = 280) for displaced femoral neck fractures using either the PL (n = 171) or the minimally invasive direct anterior approach (DAA) (n = 109). The choice of approach was related to the surgeons' practices; the implant types were similar and unrelated to the approach. Dislocation rates and other complications were reviewed after a minimum follow-up of 6 mo.

RESULTS

Both treatment groups had similarly aged patients (mean age: 82 years), sex ratios, patient body mass indexes, and patient comorbidities. Surgical data (surgery delay time, operative time, and blood loss volume) did not differ significantly between the groups. The 30 d mortality rate was higher in the PL group (9.9%) than in the DAA group (3.7%), but the difference was not statistically significant (P = 0.052). Among the one-month survivors, a significantly higher rate of dislocation was observed in the PL group (14/154; 9.1%) than in the DAA group (0/105; 0%) (P = 0.002). Of the 14 patients with dislocation, 8 underwent revision surgery for recurrent instability (posterior group), and one of them had 2 additional procedures due to a deep infection. The rate of other complications (e.g., perioperative and early postoperative periprosthetic fractures and infection-related complications) did not differ significantly between the groups.

CONCLUSION

These findings suggest that the DAA to bipolar hemiarthroplasty for patients with femoral neck fractures is associated with a lower dislocation rate (< 1%) than the PL.

Comparison of clinical outcomes of supercapsular percutaneously-assisted approach total hip arthroplasty versus conventional posterior approach for total hip arthroplasty in adults: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis was aimed to compare the postoperative clinical outcomes between the supercapsular percutaneously assisted total hip (SuperPATH, SP) and conventional posterior/posterolateral approach (PA) for total hip arthroplasty in patients who have failed conservative treatment for hip-related disorders.

METHODS

PRISMAP guidelines were followed in this systematic review. CNKI, Wanfang, PubMed, Embase, Cochrane, Web of Science databases and the reference list grey literature were searched for studies according to the search strategy. Endnote (version 20) was used to screen the searched studies according to the inclusion and exclusion criterias and extract the data from the eligible studied. RR and 95% CI were used for dichotomous variables and MD and 95% CI were used for continuous variables. All analyses and heterogeneity of outcomes were analysed by Review Manage (version 5.4). Publication bias of included studies was analysed by Stata (version 16.0).

RESULTS

Thirty-six randomized control studies were included. Compared to PA group, SP group had a shorter incision length, less intraoperative blood loss, a shorter length of hospital stay and do activities earlier. Hip function (HHS) was significantly improved within three months postoperatively. Pain of hip (VAS) was significantly reduced within one month postoperatively. The state of daily living (BI) was significantly improved within three months. Patients' overall health status (SF-36) improved significantly postoperatively. There was no difference in postoperative complications between the two approaches. PA had a shorter operative time and a higher accuracy of prosthesis placement.

CONCLUSION

The advantages of SuperPATH include accelerated functional recovery and less trauma associated with surgery. However, it required a longer operative time and implantation of the prosthesis was less accurate than that of PA.

Joint awareness among total hip arthroplasty patients operated through anterior approach versus posterior approach: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to compare joint awareness in patients who underwent total hip arthroplasty (THA) via the anterior approach (AA) versus the posterior approach (PA). The hypothesis was that patients who underwent THA via AA would have better forgetfulness of the artificial joint.

METHODS

A comprehensive search of major literature databases and bibliographic details was conducted to identify studies evaluating the forgotten joint score (FJS-12) in total hip arthroplasty (THA) patients operated through the anterior approach (AA) and posterior approach (PA). Out of 234 studies identified, seven studies met the inclusion criteria for review. The Newcastle-Ottawa Scale was used to evaluate the quality of evidence and the risk of bias in the included studies. The FJS-12 was evaluated at three months, one year, and beyond 2 years.

RESULTS

The mean FJS-12 at > 2 years was 82.03 in the AA group and 80.32 in the PA group. The forest plot analysis (n = 819 patients) revealed no significant difference in FJS-12 score between these two approaches (MD 2.13, 95% CI [- 1.17, 5.42], p = 0.21; I2 = 60%). However, the joint awareness was significantly lesser in the AA group at 3 months (MD 12.56, 95% CI [9.58, 15.54], p < 0.00001, I2 = 0%) and 1 year (MD 9.55, 95% CI [7.85, 11.24], p < 0.0001, I2 = 0%).

CONCLUSIONS

After analyzing the available literature, it was found that THA patients operated through the AA approach have significantly lower joint awareness than those operated through the PA approach in the first year of surgery. However, there is no significant difference in joint awareness between these two approaches after 2 years.

LEVEL OF EVIDENCE

III.

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

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

A systematic review and meta-analysis

Study design

Systematic Review and Meta-analysis.

Objective

To compare the complication rates associated with anterior and posterior approaches for the surgical treatment of unstable hangman's fractures.

Methods

A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in PubMed, Web of Science, and Scopus databases to identify comparative studies reporting complications of anterior versus posterior approaches for the treatment of unstable hangman's fractures.

Results

The search yielded 1163 papers from which 5 studies were fully included. One hundred fifteen (115) patients were operated on using an anterior approach versus 65 through a posterior approach. The average complication rates for the anterior and posterior approaches were 26.1 % and 13.8 %, respectively. No complications following the anterior approach required pharmacological or surgical intervention (Clavien-Dindo, Grade 1), while 88.9 % of complications following the posterior approach did (Clavien-Dindo, Grade 2).

Conclusion

No significant differences in the complication rates were found when comparing anterior versus posterior surgery for treating a C2 traumatic spondylolisthesis. However, most of the complications presented in the posterior surgery group were more severe.

A Randomised Control Trial Comparing the Outcomes of Anterior with Posterior Approach for Transfer of Spinal Accessory Nerve to Suprascapular Nerve in Brachial Plexus Injuries

Background: In brachial plexus surgery, a key focus is restoring shoulder abduction through spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer using either the anterior or posterior approach. However, no published randomised control trials have directly compared their outcomes to date. Therefore, our study aims to assess motor outcomes for both approaches. Methods: This study comprises two groups of patients. Group A: anterior approach (29 patients), Group B: Posterior approach (29 patients). Patients were allocated to both groups using selective randomisation with the sealed envelope technique. Functional outcome was assessed by grading the muscle power of shoulder abductors using the British Medical Research Council (MRC) scale. Results: Five patients who were operated on by posterior approach had ossified superior transverse suprascapular ligament. In these cases, the approach was changed from posterior to anterior to avoid injury to SSN. Due to this reason, the treatment analysis was done considering the distribution as: Group A: 34, Group B: 24. The mean duration of appearance of first clinical sign of shoulder abduction was 8.16 months in Group A, whereas in Group B, it was 6.85 months, which was significantly earlier (p < 0.05). At the 18-month follow-up, both intention-to-treat analysis and as-treated analysis were performed, and there was no statistical difference in the outcome of shoulder abduction between the approaches for SAN to SSN nerve transfer. Conclusions: Our study found no significant difference in the restoration of shoulder abduction power between both approaches; therefore, either approach can be used for patients presenting early for surgery. Since the appearance of first clinical sign of recovery is earlier in posterior approach, therefore, it can be preferred for cases presenting at a later stage. Also, the choice of approach is guided on a case to case basis depending on clavicular fractures and surgeon preference to the approach. Level of Evidence: Level II (Therapeutic).

Safety and Efficacy of Posterior Upper Rib Excision and Decompression Technique for Surgical Treatment of Neurogenic Thoracic Outlet Syndrome

BACKGROUND

There are several approaches used for surgical treatment of neurogenic thoracic outlet syndrome (n-TOS). The posterior upper rib excision and decompression technique is a novel technique that was developed and used by the author for the past 8 years. The purpose of this paper is to report clinical outcomes of patients treated with this approach.

METHODS

All patients with n-TOS operated by single surgeon from 2015 to 2023 were retrospectively analyzed. Demographic, clinical, radiologic, surgical, and postoperative data were collected and reported with emphasis on efficacy and complications. The surgical success was evaluated subjectively as excellent, good, fair, poor, and bad. Radiologic data were analyzed to assess the extent of accessory/first rib removal.

RESULTS

Eighty procedures were performed in 61 patients with a mean follow-up of 1153 (87-3048) days. The majority (60.7%) of patients were women, with 39.3% being men. In 11 cases (18%) causative factor was bone abnormality. Two patients were previously operated at another centers (3.3%). Total mean subjective improvement rate was 91.5%. More than half (55) of the patients reported "excellent" (>75%) and 6 "good" improvements (50%-75%); no fair, poor, and worse outcomes were reported. Patients reporting "good" outcome had statistically significant shorter follow-ups than the "excellent" group (P < 0.001). Complications included pleural opening, Horner syndrome, and apical hematoma, none of which were permanent.

CONCLUSIONS

The posterior upper rib excision and decompression approach provides excellent clinical outcomes in patients with n-TOS. It allows better intraoperative visualization and removal of the first rib and full decompression of the neurovascular bundle.

Selective THA-approach use amongst junior surgeons improves safety of introducing the anterior approach: a prospective, multi-surgeon, comparative, study

BACKGROUND

Learning curves associated with independent practice and anterior approach total hip arthroplasty (AA-THA) has been associated with inferior outcome. This study compared outcome of junior, fellowship-trained, surgeons who perform THA through both anterior and posterior (PA) approach, with senior surgeons who perform either AA or PA, to determine whether: 1. Fellowship training and selective practice allows for safe introduction of AA into practice; and 2. Whether selective approach-use influences outcome.

METHODS

This is a prospective, consecutive study comparing the first 800 THAs of two junior, dual-approach, surgeons (AA/PA: 455/345), with 400 THAs cases of two senior, single-approach, surgeons (AA/PA: 200/200), between 2018 and 2020. Most patients were female (54.4%), mean age was 65 years-old (range 19-96) and mean BMI was 29 kg/m2 (range 16-66). Outcome included radiologic measurements (inclination/anteversion and leg-length), complication- and revision rates, and patient-reported outcomes including Oxford Hip Score (OHS).

RESULTS

At 3.1 years (range 2.0-6.8) follow-up, there were 43 complications (3.6%), including 27 re-operations (2.3%); with no difference between junior and senior surgeons for AA-THA (Junior: 8/455 vs. Senior: 3/200; p = 0.355) or PA-THA (Junior: 11/345 vs. Senior: 5/200; p = 0.400). Amongst juniors, there was no difference in complications (AA:8/455 vs. PA:11/345; p = 0.140) and in ΔOHS (AA:20.5 ± 7.7 vs. PA:20.5 ± 8.0; p = 0.581) between approaches.

CONCLUSION

Contemporary training and selective approach-use minimizes the learning curve, allowing junior staff to have equivalent outcome to established, senior surgeons in both AA and PA. We would advocate for selective approach use amongst junior arthroplasty surgeons when introducing the AA into independent practice.

Comparing direct anterior approach versus posterior approach or lateral approach in total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

There are several approaches to THA, and each has their respective advantages and disadvantages. Previous meta-analysis included non-randomised studies that introduce further heterogeneity and bias to the evidence presented. This meta-analysis aims to present level I evidence by comparing functional outcomes, peri-operative parameters and complications of direct anterior approach (DAA) versus posterior approach (PA) or lateral approach (LA) in THA.

PATIENTS AND METHODS

A comprehensive multi-database search (PubMed, OVID Medline, EMBASE) was conducted from date of database inception to 1st December 2020. Data from randomised controlled trials comparing outcomes of DAA versus PA or LA in THA were extracted and analysed.

RESULTS

Twenty-four studies comprising 2010 patients were included in this meta-analysis. DAA has a longer operative time (MD = 17.38 min, 95%CI: 12.28, 22.47 min, P < 0.001) but a shorter length of stay compared to PA (MD = - 0.33 days, 95%CI: - 0.55, - 0.11 days, P = 0.003). There was no difference in operative time or length of stay when comparing DAA versus LA. DAA also had significantly better HHS than PA at 6 weeks (MD = 8.00, 95%CI: 5.85, 10.15, P < 0.001) and LA at 12 weeks (MD = 2.23, 95%CI: 0.31, 4.15, P = 0.02). There was no significant difference in risk of neurapraxia for DAA versus LA or in risk of dislocations, periprosthetic fractures or VTE between DAA and PA or DAA and LA.

CONCLUSION

The DAA has better early functional outcomes with shorter mean length of stay but was associated with a longer operative time than PA. There was no difference in risk of dislocations, neurapraxias, periprosthetic fractures or VTE between approaches. Based on our results, choice of THA approach should ultimately be guided by surgeon experience, surgeon preference and patient factors.

LEVEL OF EVIDENCE I

Meta-analysis of randomised controlled trials.

The posterior approach to the thoracodorsal vessels for microsurgical free tissue transfer

The latissimus dorsi (LD) muscle is a workhorse flap in reconstructive surgery (e.g., breast reconstruction, chest wall defects, and lower limb trauma). The thoracodorsal artery and its venae comitantes supply this muscle. Recipient vessel options for microsurgical free flap reconstruction of the posterior thorax and lower back are limited. The thoracodorsal vessels are an excellent option due to their reliable anatomy and ease of access. In circumstances when the patient is best positioned prone, the posterior approach to access the thoracodorsal vessels is advantageous. We describe the technique to identify and isolate these vessels via a posterior approach.

Anterior approach versus posterior approach for the open reduction of displaced pediatric supracondylar humerus fracture

Background

This study's objective was to compare the results and adverse outcomes of the anterior approach and posterior approach in patients with a type 3 Gartland pediatric supracondylar fracture who failed close treatment and indicated open reduction.

Methods

in this retrospective study patients with Gartland type 3 fracture who failed close reduction and required open reduction were enrolled in the study. Eligible patients underwent open reduction via anterior and posterior triceps sparing approaches. Patients were followed up 3, 6, and 12 months after the surgery. Study variables included age, sex, Bauman's angle, pin site infection, nerve injury, osteonecrosis, and elbow arc of motion.

Results

The study included a total of 83 patients. Surgery was performed on 49 patients using the posterior technique and 34 patients using the anterior approach. The mean age of patients was 6.78 ± 1.40 years. The mean age and the relative frequency of sex didn't differ significantly between study groups (P > 0.05). Two-way repeated measures ANOVA test showed that there was a statistically significant difference in elbow arc of motion in the anterior approach in comparison with the posterior approach, however, this increase was not clinically significant. In terms of adverse events including pin site infection, nerve injury, osteonecrosis, and cubitus varus, there was no statistically significant difference between the two approaches.

Conclusion

There was no clinically significant difference in elbow arc of motion and adverse events between the anterior approach and the posterior approach. Therefore, surgeons should choose the approach with which they are more familiar and comfortable.

Dance Around the Fibula with a Twisted Plate: A Technical Note

Nowadays, there is a better understanding of the role of the posterior malleolar fragment in trimalleolar ankle fractures. Not fragment size, but rather fragment morphology should guide the management of the posterior malleolar fracture (PMF). Anatomical reduction and fixation of the PMF is important, as an intra-articular step-off will eventually lead to osteoarthritis. Incongruency of the incisura fibularis tibia is associated with fibular dislocation, syndesmotic insufficiency, and poor functional outcomes. Open reduction and internal fixation through a posterior approach leads to ankle joint mobility restriction (i.e., dorsal flexion deficiency) due to arthrofibrosis of the ankle joint, fibrous adhesions and secondary shortening of the flexor muscles. In this technical note, we describe a surgical technique to fixate unstable ankle fractures with a combined PMF and a high supra-syndesmotic fibular fracture through two small surgical windows using a twisted one-third tubular plate. By reducing the size of the posterolateral window, fibrous adhesions and secondary flexor muscle shortening are diminished, favoring ankle joint mobility.

Intra-articular Distraction Versus Decompression to Treat Basilar Invagination Without Atlantoaxial Dislocation: A Retrospective Cohort Study of 54 Patients

OBJECTIVE

The surgical management of basilar invagination without atlantoaxial dislocation (type B basilar invagination) remains controversial. Hence, we have reported the use of posterior intra-articular C1-2 facet distraction, fixation, and cantilever technique versus foramen magnum decompression in treating type B basilar invagination as well as the results and surgical indications for this procedure.

METHODS

This was a single-center retrospective cohort study. Fifty-four patients who underwent intra-articular distraction, fixation, and cantilever reduction (experimental group) and foramen magnum decompression (control group) were enrolled in this study. Distance from odontoid tip to Chamberlain's line, clivus-canal angle, cervicomedullary angle, craniovertebral junction (CVJ) triangle area, width of subarachnoid space and syrinx were used for radiographic assessment. Japanese Orthopedic Association (JOA) scores and 12-item Short Form health survey (SF-12) scores were used for clinical assessment.

RESULTS

All patients in the experimental group had a better reduction of basilar invagination and better relief of pressure on nerves. JOA scores and SF-12 scores also had better improvements in the experimental group postoperation. SF-12 score improvement was associated with preoperative CVJ triangle area (Pearson index, 0.515; p = 0.004), cutoff value of 2.00 cm2 indicating the surgical indication of our technique. No severe complications or infections occurred.

CONCLUSION

Posterior intra-articular C1-2 facet distraction, fixation, and cantilever reduction technique is an effective treatment for type B basilar invagination. As various factors involved, other treatment strategies should also be investigated.

Cervical spine fractures in ankylosing spondylitis patients: an analysis of the presentation and clinical results of 110 surgically managed patients in two spine centers

PURPOSE

In this work, a two-center study was performed to study the clinical presentation of cervical spine fractures in ankylosing spondylitis (AS) patients and assess the surgical management of these fractures.

METHODS

A retrospective analysis of prospectively collected data in two level-1 spine surgery centers was performed. Both spine centers have a standard database for all admitted patients. Inclusion criteria were surgically treated AS with cervical spine fracture diagnosis (from C1 to Th3) and postoperative follow-up minimum of 12 months.

RESULTS

One hundred ten patients (105 male/5 female) were included. The mean age was 62 ± 10 years. The mean time between trauma and surgery was 49 ± 42 days. There was a history of mild trauma in 72 patients (65.4%). The clinical presentation was a pain in all patients. Twenty-seven (24.6%) had a neurological deficit at admission. The most common fracture level was C6/7 in 63 patients (57.23%). The VAS was 7 ± 1, and NDI was 34 ± 8 in the preoperative assessment. The mean preoperative kyphosis angle was 48 ± 26° between C2 and C7. Positioning and preparing of the patients on the operation table took a mean of 57 ± 28 min. The surgical approach was dorsal in 59 patients (53.6%), combined in 45 patients (40.9%), and ventral in 6 patients (6,5%). The mean number of the fixed levels was 6 ± 2 levels. Intraoperative complications occurred in 9 patients (8.2%). Postoperative Cobb angle improved to a mean of 17 ± 9 degrees. Neurological improvement occurred in 20/27 patients. In 12 patients, the recovery was complete. The mean postoperative follow-up was 46 ± 18 months. VAS improved to 3 ± 1, and NDI improved to 14 ± 6 at the last postoperative visit. The improvement was clinically significant (p = 0.01 and 0.00, respectively).

CONCLUSION

High suspicion of cervical spine fractures is necessary for patients with AS. CT and MRI images are necessary to rule out cervical spine fractures in AS patients, especially to detect occult fractures. Surgical treatment is safe, and the posterior approach with long-segment fusion is the approach of choice in this group of patients.

Staged Bilateral Total Hip Arthroplasty in a Patient With Larsen Syndrome

Larsen syndrome is a rare genetic disorder characterized by weak connective tissues and various musculoskeletal abnormalities. This is a case report of a 39-year-old patient with Larsen syndrome who presented with over a decade of bilateral hip pain and difficulty ambulating. This patient has a prior history of bilateral congenital hip dislocations that were treated with open reduction and spica casting as a child with good result. Years later, she went on to develop bilateral hip osteoarthritis with significant remodeling of the proximal femur. The goal of this case presentation is to demonstrate the utility of total hip arthroplasty for this patient and discuss surgical challenges and considerations.

Surgical Approaches in Total Hip Arthroplasty

The Total Hip Arthroplasty (THA) has become one of the most reliable surgical interventions that has improved the quality of life in many patients. THA allows patients to have increased mobility, range of motion, and reduced pain in patients with degenerative hip joints. This surgical procedure has become an effective treatment option for several chronic conditions affecting the hip joint. Although this surgery has been shown to give promising results in patients with hip pathology, selecting the approach for THA is a critical step in pre-operative planning. The best approach for this surgical procedure depends on multiple factors and each present with their own challenges, success rates, and limitations. To further elucidate the advantages and disadvantages associated with different surgical approaches, we critically review each surgical approach along with the different causes of failure of the THA procedure.

Multiple Hemivertebrae: The Natural History and Treatment of 50 Patients

OBJECTIVE

Multiple hemivertebrae (MHV) is defined as three or more hemivertebrae, and is relatively uncommon among patients with congenital scoliosis. This study aimed to compare the natural history of different kinds of MHV and describe the surgical outcome of MHV.

METHODS

In this retrospective cohort study, a total of 50 patients diagnosed with MHV were enrolled from June 2007 to June 2018. The medical records and radiographs of these patients were reviewed to summarize the characteristics of MHV. Patients with MHV were divided into the unbalanced (UB) group, partially unbalanced (PUB) group, and completely balanced (CB) group. Medical records and radiographs of MHV patients were reviewed to collect HV position, natural history, coronal and sagittal parameters. A Mann-Whitney U test was used to compare the radiographical data, such as the cobb angle of main curve and secondary curve, and Fisher's exact test was used to compare the patients in different kinds of MHV with surgical indication or not.

RESULTS

The average number of hemivertebrae was 3.6 and the average main curve was 57.5°. Twenty-four of 50 patients had associated anomalies, including four patients with sacral agenesis, one with tetralogy of Fallot, two with congenital imperforate anus, and 17 with Klippel-Feil syndrome. In 22 patients who underwent MRI imaging, three patients had mild syringomyelia and three patients had diastematomyelia. The UB and PUB groups had a larger main curve and compensatory curve than the CB group. Of the 25 patients with follow-up before surgery, the curve progression rate was highest in the UB group (12.1°/year) but similar in the PUB group (4.2°/year) and CB group (3.6°/year). All patients in the UB and PUB group met the criteria for surgery. In contrast, only 10 of 23 patients in the CB group had surgical indications. Eighteen of the 37 patients with surgical indications chose to undergo surgery and the correction rate of the main curve was 51.4%.

CONCLUSIONS

Early surgical intervention should be considered for most patients with UB or PUB MHV. For patients with CB MHV, surgical treatment may not be urgently needed at the first visit. Posterior hemivertebrectomy could be used for the treatment of MHV with satisfying radiographic outcome.

Anatomical variants complicating the posterior approaches towards the elbow joint

INTRODUCTION

Anatomical variants observed during the posterior approach to the elbow joint require special attention due to their clinical relevance. We aim to present a compendious review of described variants potentially encountered during the posterior approach towards the elbow joint to the experts in the elbow surgery.

METHODS

A narrative review of surgical and anatomical textbooks, as well as search of scientific databases was carried out.

RESULTS

Variability of the subcutaneous nerves is important during incision planning. Accessory muscles such as dorsoepitrochlearis, chondroepitrochlearis, epitrochleoanconeus, subanconeus or supernumerary flexor carpi ulnaris may confuse even the senior surgeon during the dissection and possibly complicate the fracture reduction. Some bony variants such as supratrochlear foramen may lead to fracture or possibly interfere with the osteosynthesis placement. Accessory bones are also present in the region of the elbow joint. Those situated intra-articular may present with symptoms.

CONCLUSION

Many variants can be encountered in the area of the elbow joint and their knowledge is essential to truly understand its anatomy. The presented review enables easier orientation in the current literature with the aim on the posterior approach towards the elbow joint.

What is the failure rate of constrained liners in complex revision total hip arthroplasty?

BACKGROUND

Recurrent hip dislocation after multiple revision total hip arthroplasty is a severe complication. Therefore, constrained acetabular liners (CL) have been used during salvage procedures. We report our experience of constrained liners in a re-revision setting with focus on re-dislocation. We also evaluated acetabular and femoral bone loss as potential risk factor.

METHODS

Between January 2013 and December 2016, 65 patients were treated in a single institution for revision and re-revision hip arthroplasty using CL. The indication for using a CL was a high risk of re-redislocation after multiple recurrent hip dislocation including failed Dual Mobility Cups (DMC). Compromising soft tissue defects as well as severe bone defect were therefore regarded as high risks. Thirty-eight patients (77.6%) underwent a minimum of three surgical procedures before the index revision procedure. Sixteen patients (24.6%) were excluded as they were lost to follow-up, expired before minimum follow-up or refused study participation, leaving 49 patients in the analysis (75.4%). The mean follow-up was 62 months (44-74; SD = 7.7). We assessed the following potential risk factors for revision or dislocation: type of surgical setting (septic/aseptic), BMI, cup inclination angle, size of liner used and acetabular and femoral bone loss according to Paprosky classification. The primary endpoints were dislocation or repeat revision for any reason.

RESULTS

Of the 49 patients, we found an overall re-revision rate of 40.8% (20/49) and a dislocation rate of 30.6% (15/49). There were no significant differences among the surgical re-revision rate or dislocation rate as a factor of patient characteristics. In terms of bone loss, there was a trend towards higher revision rates for increasing acetabular and femoral bone loss, but without statistical significance.

CONCLUSIONS

We found the use of a constrained liner in a re-revision setting still bears a high risk of re-revision and re-dislocation. Therefore we restrained from using constrained liners in favour of Dual mobility cups. In this study there was no significant higher dislocation rate in the subgroup of periprosthetic infection. Furthermore the rigid design of a constrained liner bears the known risk of structural failure of acetabular reconstruction implants. Severe acetabular or femoral bone defects seem to have an impact on the revision rate, but not on the dislocation rate with regards to the restored offset and center of the hip. Results have to be taken into context such that the study population inherently has a predisposition for poorer outcomes. Indications should be strongly filtered for patients at high risk for recurrent hip joint dislocation including failed DMCs with only limited bone loss and moderate soft tissue defects. Our modification to the existing classification with a high inter and intraobserver reliability will make future studies more comparable regarding revisions and bone stock loss. Still further research using objective and reproducible parameters is needed to better analyze data especially in the background of complex revision hip arthroplasty.

[Translated article] Posterior malleolar fractures: Indications and surgical approaches

Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.

Posterior malleolar fractures: Indications and surgical approaches

Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2 mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2 mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.

Cervical alignment and clinical outcome of open-door laminoplasty vs. laminectomy and instrumentation in kyphotic multilevel cervical degenerative myelopathy

INTRODUCTION

The aim of this study was to determine whether the sagittal lordotic alignment, clinical outcomes and axial symptoms (AS) could be improved by kyphotic correction through the posterior approach for the treatment of multilevel cervical degenerative myelopathy (CDM) and to further analyze the changes of cervical spinal alignment parameters after correction of kyphosis. The hypothesis was that correction of kyphosis can improve the severity of AS and neurological recovery.

MATERIALS AND METHODS

We retrospectively reviewed 109 patients who suffered from multilevel CDM combined with kyphosis. The patients had undergone open-door laminoplasty (Group LP, 53 patients) and laminectomy with instrumentation (Group LI, 56 patients) between January 2014 and December 2018. Cervical spinal alignment parameters, including curvature index (CI), T1 slope, C2-7 Cobb angle, C2-7 SVA, were measured on the pre- and postoperative lateral radiographs. The recovery rate was calculated based on the Japanese Orthopedic Association (JOA) score. AS severity was quantified using Neck Disability Index (NDI). A P value less than 0.05 was considered to be significant.

RESULTS

Analyses of postoperative follow-up data showed significant differences (P < 0.001) in CI, correction of CI, C2-7 Cobb angle, T1 slope, C2-7 SVA and NDI between Group LP and LI, but no significant differences in JOA score (P = 0.23) and recovery rate (P = 0.13). There were significant differences (P < 0.001) in CI, T1 slope, C2-7 Cobb angle, C2-7 SVA, JOA score, and NDI between pre- and postoperative follow-up in both groups. Correction of CI showed negative correlation with AS severity (r = -0.51, P < 0.001), and no association with recovery rate (r = 0.14, P = 0.15).

CONCLUSIONS

Satisfied neurological improvement was achieved by LP and LI for multilevel CDM combined with kyphosis. Cervical kyphotic correction produced significant improvement of AS and increase of T1 slope and C2-7 SVA. However, the kyphotic correction may not be associated with better neurological recovery in the short-term postoperative period.

Surgical Approach to Cervical Fractures in Ankylosing Spondylitis Patients: Rationale and Surgical Strategy

BACKGROUND

Current literature lacks objective criteria to determine surgical management in patients with ankylosing spondylitis who sustain cervical fractures. The purpose of our study was to analyze the determinants for stratifying surgical approach, evaluate the outcome in patients, and postulate a management strategy.

METHODS

This was a retrospective study of patients with ankylosing spondylitis who underwent surgery for cervical spine injury with a minimum follow-up of 2 years. Neurological recovery, fracture pattern including translation and angulation, surgical duration, blood loss, and postoperative complications were recorded, and a comparative analysis of these factors with anterior, posterior, and combined surgical approaches was performed.

RESULTS

The study included 43 men with a mean age of 57 years; 49% underwent anterior-only stabilization, 16% underwent posterior-only stabilization, and 35% underwent combined anteroposterior stabilization. Mean operative time was significantly lower in anterior-only (81.4 minutes; P < 0.05) and posterior-only (124 minutes; P < 0.05) approaches compared with combined approach (266.6 minutes). Mean blood loss was significantly lower in anterior-only (87.5 mL, P < 0.05) approach compared with posterior-only (714.7 mL) and combined (912.7 mL) approaches. Mean translation was 1.8 mm, 1.7 mm, and 3.7 mm in anterior, posterior, and combined approaches (P < 0.05), respectively.

CONCLUSIONS

Our study provides insights into management of cervical spine fractures in ankylosing spondylitis patients. A fracture displacement ≤2 mm may be successfully managed by an anterior approach, while the posterior approach may be beneficial in similar fractures warranting instrumentation extending to the thoracic spine. All other fractures warrant a combined surgical approach.

Open reduction and internal fixation for posterior pilon fracture: Transfibular approach versus posterior approach

BACKGROUND

For posterior pilon fractures, the posterior approach (PA) is widely used but has its limitations. The transfibular approach (TFA) has been adopted to treat posterior malleolar fractures for the advantage of direct visual confirmation of the reduction status intraoperatively, yet the report of its application on posterior pilon fractures is rare. This study aims to compare TFA with PA in terms of their corresponding reduction quality.

METHODS

Clinical data of 85 posterior pilon fracture patients treated via PA (n = 62) or TFA (n = 23) were retrospectively reviewed. Radiographic and clinical assessments, including articular step-off or gap, syndesmosis reduction quality, signs of ankle arthritis, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), ankle stability, and the active range of motion (ROM) of the ankle, were all evaluated by two readers independently.

RESULTS

The total incidence of step-off or gap ≥ 1 mm was significantly higher in the PA group (35.5%) than in the TFA group (8.7%, p = 0.015). In all the patients, step-off ≥ 1 mm was identified as an independent risk factor for the development of arthritis and a lower AOFAS score (p < 0.001). No significant difference was found in ROM and complication incidence between the two groups. Ankle instability was found in neither group during the follow-up.

CONCLUSION

TFA could offer a way to intraoperatively evaluate the reduction status with direct visual confirmation and, thereby, might improve the results of reduction for posterior pilon fractures.

LEVEL OF EVIDENCE

Level III.

Posterior Multisegment Apical Convex plus Concave Intervertebral Release Combined with Posterior Column Osteotomy for the Treatment of Rigid Thoracic/Thoracolumbar Scoliosis

BACKGROUND

Intervertebral release (IVR) in the apical region is critical for full release of a rigid spine. Previous studies have mainly reported IVR techniques using an anterior approach or posterior apical convex IVR. We first report the surgical procedure of posterior multisegment apical convex plus concave IVR combined with posterior column osteotomy (PCO) for treating rigid thoracic/thoracolumbar scoliosis.

METHODS

This study retrospectively analyzed clinical, radiologic outcomes and technique notes of 18 patients with rigid scoliosis treated with posterior multisegment convex plus concave IVR combined with PCO.

RESULTS

The preoperative, postoperative, and final follow-up mean sagittal Cobb angles of the main curve were 75.2° (58.7°-110.2°), 18.4° (9°-35.1°), and 19.0° (8.2°-36.3°), respectively. The mean correction rate was 75.3% (66.7%-86.7%). In cases of thoracolumbar kyphosis, the preoperative, postoperative, and final follow-up mean sagittal Cobb angles were 45.7° (40.5°-52.6°), 18.8° (10.2°-27.5°), and 19.8° (11.1°-29°), respectively. The mean correction rate was 57% (42.1%-72.6%). The mean axial vertebral rotation (AVR) in the IVR region was 24.4° (14.3°-46.3°) preoperatively and was corrected to 10.9° (10.9°-26.6°) postoperatively. The mean correction rate for AVR was 55.9% (41.1%-78.6%). The coronal and sagittal Cobb angles and AVR postoperatively were significantly lower than those preoperatively (P < 0.001). This case series reported 2 cases of pleural effusion and 1 case of wound infection.

CONCLUSIONS

Single posterior multilevel apical convex plus concave IVR combined with PCO is a safe and effective surgical method for treating rigid thoracic/thoracolumbar scoliosis that does not need 3-column osteotomy.

The Impact of Varying Femoral Head Length on Hip External Rotation During Posterior-approach Total Hip Arthroplasty

Background

Prior investigations of total hip arthroplasty (THA) have studied the effects of prosthetic femoral head size and stem offset on hip range of motion (ROM), impingement risk, and overall hip stability to optimize the return to activities of daily living. However, the relationship between femoral head length and hip ROM, specifically external rotation (ER), has not been evaluated. The aim of our study was to intraoperatively assess how femoral head length affects hip ROM during a posterior approach THA.

Methods

Thirty-two patients undergoing a primary elective THA through a posterior approach were prospectively included. After final femoral stem insertion, femoral head trials were performed using the targeted head length, followed by the shorter (-3.0 to -3.5 mm) and longer (+3.0 to +4.0 mm) head length configurations. At each length, hip ER was measured using an intraoperative goniometer from an imageless navigation system. ER values across the three head lengths were compared using a repeated-measures analysis of variance and paired t-tests.

Results

Varying femoral head lengths demonstrated a statically significant and reproducible effect on intraoperative ER range (analysis of variance; P < .001) in each patient. An increased femoral head length (mean 3.4 mm) significantly decreased (P < .001) ER range by 10.8 ± 3.3° while a shortened femoral head length (mean 3.5 mm) significantly increased (P < .001) the ER ROM by 6.0 ± 3.8°.

Conclusions

The results of this study demonstrate the sensitivity of hip ROM to incremental changes in femoral head length. As ER is important for activities of daily living, inadvertent lengthening should be avoided.

Surgical Decompression of Thoracic Ossification of the Posterior Longitudinal Ligament through Posterior Approach: A Case Report

Thoracic ossification of the posterior longitudinal ligament (OPLL) is a rare condition that is mainly accompanied by cervical OPLL or ossification of thoracic ligamentum flavum. In case of causing neurological manifestations, it is preferred to treat the condition surgically. Several surgical procedures were introduced, including anterior, posterior, or combined approaches. Laminectomy with instrumented fusion is the most popular procedure utilized via the posterior approach. A 32-year-old obese woman, who suffered from back pain and weakness in both lower extremities for one month, was referred to our spine outpatient clinic. Imaging revealed lower thoracic OPLL (T7/T8 & T8/T9 & T9/T10). The posterior longitudinal ligament had a mixed ossification pattern (beaked and continuing cylindrical). To maintain thoracic spine stability and prevent future kyphosis, we performed laminectomy and long segment fixation (T7 to T12). The post-operative neurological examination revealed a considerable increase in muscle strength and significant pain relief.

Safety and effectiveness of a posterior approach alone for surgical treatment of sacral-presacral tumors

Aim

We aimed to examine the safety and effectiveness of a posterior approach alone in the surgical treatment of sacral-presacral tumors. In addition, we investigate factors that determine the selection of a posterior approach alone.

Materials and Methods

Patients with sacral-presacral tumors who underwent surgery in our institution between 2007 and 2019 were examined in this study. Data regarding patient age, gender, tumor size (>6 cm and <6 cm), tumor localization (below or above S1), tumor pathology (benign or malignant), surgical approach (anterior alone, posterior alone, or combined), and extent of resection were recorded. The Spearman's correlation analyses were conducted between surgical approach and tumor size, localization, and pathology. Factors influencing the extent of resection were also examined.

Results

Complete tumor resection was achieved in 18 of 20 patients. A posterior approach alone was used in 16. No strong or significant relation was detected between surgical approach and tumor size (r = 0.218; P = 0.355). There was no strong or significant relationship between surgical approach and tumor localization (r = 0.145; P = 0.541) or tumor pathology (r = 0.250; P = 0.288). Tumor size, localization, and pathology were not independent factors that determined surgical approach. The only significant independent determining factor for incomplete resection was tumor pathology (r = 0.688; P = 0.001).

Conclusion

A posterior approach is safe and effective in the surgical treatment of sacral-presacral tumors independent of tumor localization, size, or pathology and is a feasible first-line treatment option.

The use of a modified posterior approach (SPAIRE) may be associated with an increase in return to pre-injury level of mobility compared to a standard lateral approach in hemiarthroplasty for displaced intracapsular hip fractures: a single-centre study of the first 285 cases over a period of 3.5 years

BACKGROUND AND PURPOSE

A tendon-sparing modification of the posterior approach to the hip joint was introduced in the specialist hip unit at our institution in 2016. The SPAIRE technique-acronym for "Saving Piriformis And Internus, Repair of Externus" preserves the insertions of gemellus inferior, obturator internus, gemellus superior and piriformis intact. We compare the results of the first 285 hip hemiarthroplasty patients, unselected but preferentially treated by our hip unit surgeons using the SPAIRE technique, with 567 patients treated by all orthopaedic surgeons (including the hip unit) in the department over the same 3.5 year period using the standard lateral approach. We report length of stay, return to pre-injury level of mobility, place of residence and mortality at 120 days.

PATIENTS AND METHODS

The review included all hemiarthroplasty patients. Pre-fracture mobility and place of residence, surgical approach, grade of senior surgeon in theatre, stem modularity, acute and overall length of stay, mobility, place of residence, re-operations and mortality at 120 days were recorded. Data were obtained from the National Hip Fracture Database that included a telephone follow-up at 120 days and from electronic patient records.

RESULTS

The odds of returning to pre-injury level of mobility were higher in the SPAIRE technique group than in the standard lateral group; adjusted odds ratio (95% confidence interval (CI)) 1.7 (1.1 to 2.7, p = 0.01).

INTERPRETATION

When used in hip hemiarthroplasty, the SPAIRE technique appears safe and may confer benefit in maintaining the pre-injury level of mobility over the standard lateral approach.

Staged Bilateral Total Hip Arthroplasty in a 17-Year-Old With Type VI Mucopolysaccharidosis

Mucopolysaccharidosis encompasses multiple lysosomal storage disorders that are relevant to the orthopedic surgeon as they lead to disruption in bone and cartilage development. These patients may present with early-onset joint pain, including end-stage hip arthritis warranting total hip replacement. The altered hip anatomy in this disorder is of specific importance to the arthroplasty surgeon as it presents challenges when reconstructing the proximal femur and acetabulum and informs implant choice. We present a 17-year-old patient with end-stage bilateral hip arthritis who underwent staged bilateral total hip arthroplasty. We discuss technical considerations in surgical technique and the consequences of acetabular and femoral deformity on implant selection.

A prospective study comparing three different all-posterior surgical techniques in the management of thoracolumbar spinal tuberculosis

Background

Posterior only surgery has been widely performed in the treatment of thoracic and lumbar spinal tuberculosis. Surgical options include debridement with posterior instrumentation only or combined with anterior reconstruction. The aim of this study is to investigate and compare the clinical, functional and radiological outcomes using a single-stage posterior only surgery in thoracolumbar spinal tuberculosis by three different surgical techniques.

Methods

Patients undergoing posterior only surgery for thoracic and lumbar spinal tuberculosis were followed up prospectively and included. Three different procedures, Group-A: Posterior instrumentation with anterior cage reconstruction (n = 49), Group-B: Posterior instrumentation and anterior autologous bone-grafting (n = 21) and Group-C: Posterior column shortening without anterior-reconstruction (n = 52) were compared for kyphosis correction achieved, kyphosis at final follow-up and degree of correction lost. Neurological assessment was done using ASIA impairment Scale(AIS) grades. Functional assessment was done using Visual analogue score (VAS), Modified McNab criteria and NASS satisfaction score.

Results

A total of 122 patients were included in the study, Group-A (49), Group-B (21) and Group-C (52). Radiological correction of kyphotic deformity in anterior reconstruction, Group-A (20.17 ± 9.25⁰) was higher than 13.97⁰ ± 6.06⁰ and 14.27⁰ ± 6.47⁰ achieved in Groups B and C respectively. There was no significant difference in correction lost amongst the three groups (p-value, 0.76). Surgical duration, blood loss and hospital stay were significantly higher in the anterior reconstruction group (p-value, 0.001). Similarly, no significant difference was noted between the three groups in neurological and functional outcomes at 2 years.

Conclusion

Posterior only approach is eminently satisfactory for treating Thoracolumbar Spinal Tuberculosis (STB). All three groups had similar functional and neurological outcomes. However there was a better correction of deformity in patients with anterior cage reconstruction.

Pain and rehabilitation after total hip arthroplasty are approach dependent: a multisurgeon, single-center, prospective cohort study

PURPOSE

The aim of this study was to assess perioperative pain and mobilization after total hip arthroplasty (THA) using three different surgical approaches.

METHODS

This was a multisurgeon, prospective, single-center cohort study. A total of 188 patients who underwent hip arthroplasty (THA) between February 2019 and April 2019 were analyzed according to the surgical approach used (direct anterior, lateral, and posterior approach). Outcome parameters were the daily walking distance during the inpatient stay, the pain level according to the visual analog scale (VAS) at rest and motion during the inpatient stay and at 6-week follow-up and the modified Harris Hips Score (mHHS) preoperatively and at 6 weeks.

RESULTS

The walking distance within the groups increased significantly during the inpatient stay (p < 0.001). The DAA and posterior approach patients had a significantly longer walking distance than the lateral approach patients on the third postoperative day (DAA vs. lateral, p = 0.02; posterior vs. lateral 3, p = 0.03). DAA and posterior approach patients reported significantly less pain during motion on the third postoperative day and at 6-week follow-up than the lateral approach patients (3 postoperative day: DAA vs. lateral, p = 0.011; posterior vs. lateral, p = 0.04; 6 weeks control: DAA vs. lateral, p = 0.001; Posterior vs. lateral 3, p = 0.005). The mHHS demonstrated significant improvement within each group. However, lateral approach patients reported significantly less improvement than the DAA and posterior approach patients (DAA vs. lateral, p = 0.007; posterior vs. lateral, p = 0.021).

CONCLUSION

This study analyzed perioperative pain progression and short-term rehabilitation after THA according to the different surgical approaches. Direct anterior and posterior approaches have shown comparable improvements in pain, walking distance, and mHHS. Whether this effect persists over a longer period of time must be clarified in future studies.

STUDY DESIGN

Prospective cohort study, level of evidence, 2.

Open Reduction for Potentially Reducible Atlantoaxial Dislocation Secondary to Transverse Ligament Laxity in Patients with Rheumatoid Arthritis

OBJECTIVE

Atlantoaxial dislocation (AAD) is classified into reducible AAD and irreducible AAD (IRAAD). Anterior or posterior releasing followed by occipitocervical/atlantoaxial fusion is often performed for IRAAD, but is technically demanding. This study aimed to evaluate the results of the posterior open reduction technique without releasing the atlantoaxial joint in the treatment of potentially reducible AAD (PRAAD) caused by transverse ligament laxity in patients with rheumatoid arthritis (RA).

METHODS

Data from 38 RA patients who experienced PRAAD due to transverse ligament laxity were retrospectively reviewed. They all underwent posterior open reduction and fusion without releasing the atlantoaxial joint. Outcomes were evaluated by using atlantodental interval, modified Japanese Orthopedic Association scores, Nurick grade, Neck Disability Index, and visual analog scale score for neck pain.

RESULTS

All the patients achieved solid bone fusion at follow-up. The mean atlantodental interval was reduced to 5.6 ± 0.7 mm and 2.1 ± 0.5 mm after traction and operation, respectively, from a preoperative score of 8.2 ± 0.6 mm (P < 0.05). Compared with the respective preoperative values, the mean modified Japanese Orthopedic Association score and Nurick grade were significantly increased at the final follow-up (both P < 0.05), whereas the Neck Disability Index and visual analog scale score for neck pain were significantly decreased (both P < 0.05).

CONCLUSIONS

AAD with partial reduction after skeletal traction for 48 hours should be defined as PRAAD, not IRAAD. Open reduction with a C1-C2 pedicle screw-rod system can be safely and effectively applied in the treatment of PRAAD due to transverse ligament laxity in patients with RA.

Comparative MRI assessment of three minimally invasive approaches in total hip arthroplasty

INTRODUCTION

Minimally invasive approaches (direct anterior approach: DAA; minimally invasive anterolateral: MIAL; piriformis-sparing posterior approach: PSPA) are widely used for total hip arthroplasty (THA), with a muscle-sparing objective. There are no published comparative studies of muscle damage secondary to these approaches. The aim of the present study was to compare fatty infiltration (FI) on MRI induced by DAA, MIAL and PSPA in THA 1) in the tensor fasciae latae (TFL) and sartorius muscles, 2) in the gluteal muscles, and 3) in the pelvitrochanteric muscles.

HYPOTHESIS

Greater FI is induced by DAA in anterior muscles, by MIAL in gluteal muscles and by PSPA in pelvitrochanteric muscles.

MATERIALS AND METHODS

Three continuous prospective series of THA by DAA, MIAL and PSPA included 25 patients each. MRI was performed preoperatively and at 1 year postoperatively. FI was graded on the Goutallier classification in all periarticular hip muscles. Muscles showing ≥2 grade aggravation at 1 year were considered damaged.

RESULTS

Nine patients whose preoperative MRI was uninterpretable were excluded. In all, 66 patients (21 DAA, 24 MIAL and 21 PSPA) with 132 MRI scans were analyzed. TFL was damaged in 2/21 DAA patients (9.5%), 1/24 MIAL patients (4.2%) and 0/21 PSPA patients (0%). There were no sartorius lesions. The anterior third of the gluteus medius was damaged in 8/24 MIAL patients (33.3%) and the gluteus minimus in 10/24 (41.7%), compared to 1/21 DAA patients (4.8%) and 0/21 PSPA patients (0%). The mid and posterior thirds of the gluteus medius and the gluteus maximus were never damaged. The piriformis muscle was damaged in 3/21 DAA patients (14.3%), 2/24 MIAL patients (8.3%) and 2/21 PSPA patients (9.5%). The obturator internus was damaged in 4/21 DAA patients (19%), 1/24 MIAL patients (4.2%) and 16/21 PSPA patients (76.2%). The obturator externus and quadratus femoris were mainly damaged in PSPA patients: respectively, 5/21 (23.8%) and 4/21 patients (19%)).

CONCLUSION

The muscle-sparing properties of minimally invasive hip approaches are only theoretical. In the present series, there were rare TFL lesions with DAA and MIAL. Gluteus medius and minimus lesions were frequent in MIAL. Pelvitrochanteric muscles lesions were more frequent in PSPA, but found in all 3 approaches. These findings should help guide surgeons in their choice of approach and in informing patients about the damage these minimally invasive approaches can cause.

LEVEL OF EVIDENCE

III, prospective comparative study.

Cup orientation following posterior approach THA - the effect of different visual aids and pelvic supports

Introduction

This study aims to compare cup inclination achieved (1) Using two orientation guides, whilst using the same 3-point pelvic positioner and (2) Using two types of pelvic positioners, whilst measuring intra-operative cup inclination with an inclinometer.

Materials and methods

This is a prospective, diagnostic cohort study of a consecutive series of 150 THAs performed through a posterior approach. Two types of 3-point pelvic positioners were used (Stulberg and modified Capello Hip Positioners) and the cup was positioned freehand using one of two orientation guides (mechanical guide or digital inclinometer). Intra-operative inclination was recorded, radiographic cup inclination and anteversion were measured from radiographs. The differences in inclination due to pelvic position (ΔPelvicPosition) and orientation definitions (ΔDefinition) were calculated. Target radiographic inclination and anteversion was 40/20° ± 10°.

Results

There was no difference in radiographic cup inclination/ (p = 0.63) using a mechanical guide or digital inclinometer. However, differences were seen in ΔPelvicPosition between the positioners ((Stulberg: 0° ± 5 vs. Capello: 3° ± 6); p = 0.011). Intra-operative inclination at implantation was different between positioners and this led to equivalent cases within inclination/anteversion targets (Stulberg:84%, Capello:80%; p = 0.48).

Conclusions

With the pelvis securely positioned with 3-point supports, optimum cup orientation can be achieved with both alignment guides and inclinometer. Non-optimal cup inclinations were seen when intra-operative inclinations were above 40° and below 32°, or the ΔPelvicPosition was excessive (> 15°; n = 2). We would thus recommend that the intra-operative cup inclination should be centered strictly between 30° and 35° relative to the floor. Small differences exist between different type of pelvic positioners that surgeons need to be aware off and account for.

Postoperative Opioid Use Following Single-Level Transforaminal Lumbar Interbody Fusion Compared with Posterolateral Lumbar Fusion

OBJECTIVE

To compare postoperative opioid morphine milligram equivalents (MME) prescriptions for opioid-naïve patients undergoing single-level transforaminal lumbar interbody fusion (TLIF) versus posterolateral lumbar fusion (PLF) and total postoperative MME prescribed based on operative duration.

METHODS

Patients undergoing single-level TLIF or PLF from September 2017 to June 2020 were identified from a single institution. Patients were first grouped based on procedure type (TLIF or PLF) and subsequently regrouped based on median operative duration. Statistical tests compared patient demographics and opioid prescription data between groups. Multivariate regressions were performed to control for demographics, operative time, and procedure type.

RESULTS

Of 345 patients undergoing single-level PLF or TLIF, 174 (50.4%) were opioid-naïve; 101 opioid-naïve patients (58.0%) underwent PLF and 73 (42.0%) underwent TLIF. Patients undergoing TLIF received more opioid prescriptions (1.99 vs. 1.26, P < 0.001) and total MME (91.2 vs. 66.8, P = 0.002). After regrouping patients based on operative duration, independent of procedure type, there were no differences in postoperative opioid prescriptions, and Spearman rank correlation coefficient between total MME and operative duration was r = 0.014. Multivariate analysis identified TLIF as an independent predictor of increased postoperative opioid prescriptions (β = 0.64, P < 0.001), prescribers (β = 0.49, P = 0.003), and MME (β = 24.4, P = 0.030).

CONCLUSIONS

Opioid-naïve patients undergoing single-level TLIF receive a greater number of postoperative opioids than patients undergoing single-level PLF, and TLIF was an independent predictor of increased postoperative opioid prescribers, prescribers, and MME. There were no differences in postoperative opioid prescriptions when assessing patients based on operative duration.

The ability and factors related with floor sitting after total hip arthroplasty with a posterolateral approach

Background

Prosthesis dislocation following total hip arthroplasty (THA) is one complication that affects treatment outcome and increases the cost of treatment. Currently, many surgeons prohibit patients from performing floor-based activities; however, these prohibitions might affect the lifestyle of a number of patients.

Objective

This study aimed to evaluate the ability of floor sitting after THA, and factors associated with this ability.

Methods

This study was a retrospective cohort study, evaluating 240 patients who underwent THA with a posterolateral approach, in a single tertiary hospital. Patient demographic data, preoperative clinical data, prostheses type, and postoperative radiographic were extracted from the electronic medical records. Postoperative ability to perform floor sitting was evaluated at 6 months postoperatively.

Results

There were 52 patients (21.66%) who were able to sit on the floor postoperatively. Multivariate logistic regression analysis showed independent association between three factors with ability to sit on the floor after surgery: pre-operative external rotation range of motion (OR 1.03; 95% CI, 1.01-1.06; P = 0.01), pre-operative Harris Hip Scores (OR 1.05; 95% CI, 1.01-1.10; P = < 0.01), pre-operative ability to sit on the floor (OR 10.2; 95% CI, 3.65-28.5; P = < 0.01).

Conclusion

There were a number of patients who could sit on the floor after THA. However, there were factors which were associated with this ability. Hence, these results could be useful for adjusted patient preoperative expectations, and did not preclude all patients to perform floor activities.

Surgical exposure to posterolateral quadrant tibial plateau fractures: an anatomic comparison of posterolateral and posteromedial approaches

BACKGROUND

Management of posterolateral tibial plateau quadrant fractures can be challenging, and two posterior approaches were frequently used for exposure, reduction, and fixation: posterolateral approach and posteromedial approach. The purpose of this study was to compare their deep anatomical structure and analyze their limits and the risk of injury to important structures during surgical dissection of two approaches.

METHOD

Five lower limb specimens were used in this study. After dissection of the skin and superficial fascia of each specimen, deep structures were dissected via posteromedial and posterolateral approach, and several parameters including perpendicular distance from the anterior tibial artery coursing through the interosseous membrane fissure to the lateral joint line and apex of fibular head and so on were measured and analyzed.

RESULT

The perpendicular distance from the ATA coursing through the interosseous membrane fissure to the lateral joint line was 49.3 ± 5.6 mm (range 41.3-56.7 mm), while the distance to the apex of fibular head was 37.7 ± 7.2 mm (range 29.0-48.0 mm). The transverse distance of the anterior tibial vascular bundle is around 10 mm. The perpendicular distance from the top accompanying vein of the ATA bundle to lateral joint line and apex of fibular head was 44.1 ± 6.3 mm and 32.5 ± 7.6 mm, respectively. The maximum proportion of posterolateral tibial plateau shielded by the fibular head from the posterior view was 61.7 ± 4.9% (range 55.6-64.1%). The average length of popliteus muscle outside the joint was 83.1 ± 6.0 mm (range 76.5-92.2 mm), and the width in the middle was 28.1 ± 4.3 mm (range 26.6-29.1 mm).

CONCLUSION

Although posterolateral approach seems more direct for exposure of posterolateral quadrant tibial plateau fracture, it has three major disadvantages in deep dissection. Posteromedial approach through the medial board of medial head of gastrocnemius-soleus may be safer, but it was hard for direct visualization of articular surface which limits it usage for only a few cases.

Three-column osteotomy by single-stage posterior approach in congenital and post-tubercular kyphosis: a comparison of outcomes

PURPOSE

To compare the clinical, radiological and functional outcomes of three-column osteotomy (3CO) by a single-stage posterior approach in patients with isolated congenital angular kyphosis (CK) and healed post-tubercular kyphosis (PTK).

METHODS

The hospital records of 30 patients with isolated congenital kyphosis (Group CK) and 51 patients with healed post-tubercular kyphosis (Group PTK), operated at a single centre utilizing a 3CO by a single-stage posterior-only approach, were retrospectively analysed. The two groups were compared with respect to selected demographic variables with clinical, radiological and functional outcome measures at a minimum follow-up of 24 months.

RESULTS

Patients in Group CK (median: 13 years, range: 4-30 years) presented earlier than those in Group PTK (median: 16 years, range: 6-45 years). The apex of the deformity was most often located in the thoracic spine in Group PTK, and in the thoracolumbar or lumbar spine in Group CK. The mean operative time (198.2 ± 31.5 min v/s 174.4 ± 34.5; p = 0.01) and estimated blood loss (859.6 ± 312.2 ml v/s 720.8 ± 187.3; p = 0.04) were significantly higher in Group PTK. While the local kyphosis angle was significantly corrected with surgery in both groups, the correction was significantly better in Group CK-this group also had significantly better overall functional (SRS-22r) scores at a follow-up of 24 months (p < 0.05). The overall complication rate (29.4% v/s 23.3%) and neurological complication rate (9.8% v/s 6.6%) were higher in Group PTK. Permanent neurological deterioration occurred in one patient in each group.

CONCLUSION

Patients with PTK have significantly higher age of presentation, higher operative time and higher complication rate as compared to CK. However, good functional outcomes and kyphosis angle correction can be achieved in both the groups with posterior-only three-column osteotomies.

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.