A comparison between the direct anterior and posterior approaches for total hip arthroplasty: the role of an 'Enhanced Recovery' pathway.

AIMS: We assessed the difference in hospital based and early clinical outcomes between the direct anterior approach and the posterior approach in patients who undergo total hip arthroplasty (THA). PATIENTS AND METHODS: The outcome was assessed in 448 (203 males, 245 females) consecutive patients undergoing unilateral primary THA after the implementation of an 'Enhanced Recovery' pathway. In all, 265 patients (mean age: 71 years (49 to 89); 117 males and 148 females) had surgery using the direct anterior approach (DAA) and 183 patients (mean age: 70 years (26 to 100); 86 males and 97 females) using a posterior approach. The groups were compared for age, gender, American Society of Anesthesiologists grade, body mass index, the side of the operation, pre-operative Oxford Hip Score (OHS) and attendance at 'Joint school'. Mean follow-up was 18.1 months (one to 50). RESULTS: There was no significant difference in mean length of stay (p = 0.07), pain scores on the day of surgery, the first, second and third post-operative days (p = 0.36, 0.23, 0.25 and 0.59, respectively), the day of mobilisation (p = 0.12), the mean OHS at six and 24 months (p = 0.08, and 0.29, respectively), the incidence of infection (p = 1.0), dislocation (p = 1.0), re-operation (p = 0.21) or 28 days' re-admission (p = 0.06). Significantly more patients in the DAA group achieved a planned discharge target of three days post-operatively (68% vs 56%, p = 0.007). The rate of periprosthetic femoral fractures was significantly higher in the DAA group (p = 0.04). CONCLUSION: We conclude that there is no difference in clinical outcomes between the DAA and the posterior approach in patients undergoing THA when an 'Enhanced Recovery' pathway is used. However, a significantly higher rate of periprosthetic femoral fractures remains a concern with the DAA, even in experienced hands. TAKE HOME MESSAGE: Our results show that the DAA for THA is not superior to posterior approach when 'Enhanced Recovery' pathway is used. Cite this article: Bone Joint J 2016;98-B:754-60.

Acute repair of injury to the anterior cruciate ligament. A long-term followup.

We reviewed 30 patients at an average of 7.4 years after acute repair of the anterior cruciate ligament augmented with a loop of iliotibial tract. A noncontact twisting had been the mechanism of injury in 18 of these patients, with 28 having been injured in sports. At followup, 25 patients had not experienced symptoms of instability and 23 were able to return to unrestricted athletic activity; only 5 had been unable or unwilling to return to sporting activity at all. There had been no swelling in 23 patients; however, 17 suffered from pain on exertion. The average Lysholm score was 93.2. Joint laxity was assessed and anteroposterior tibial translation quantified with a KT-1000 arthrometer. Eighteen patients had a normal or 1+ Lachman test and 27 had an absent or 1+ pivot shift. When compared with the results of a similar study performed on this group of patients at 2 years after surgery, there had been little subjective change in knee function. However, objectively there had been significant deterioration of the anteroposterior stability of the knees at 7 years, suggesting failure of the integrity of the repaired ligament with time. An associated medial collateral ligament injury had a significant adverse effect both on the integrity of the anterior cruciate ligament repair and the incidence of postoperative stiffness.

Avulsion of the ischial apophysis. The case for open reduction and internal fixation.

We report three cases of avulsion of the ischial tuberosity with marked chronic disability after delay in diagnosis and non-union of the fracture. All were treated by open reduction and internal fixation with return to full function, allowing in one case, athletic performances of Olympic standard. We also report one patient with an acute apophyseal avulsion treated by early reduction and internal fixation with restoration of full function.

Patellofemoral malalignment: a report of 68 cases treated by proximal and distal patellofemoral reconstruction.

A series of 68 knees were reviewed retrospectively at an average of 56 months following surgical treatment for patellar dislocation and subluxation. Fifty-three knees in 48 patients were assessed both subjectively by questionnaire and objectively by examination, and 15 knees were evaluated by questionnaire only. All cases were treated by a proximal and distal reconstruction as described by Trillat (1964). The surgery was performed by one surgeon (MC) and reviewed independently (DW). The results were excellent in 48 knees (71 per cent), good in 12 (17 per cent) and poor in 8 (12 per cent). In no patient had there been any further episodes of dislocation. We consider this a straightforward procedure producing consistent correction of patellofemoral instability with a low morbidity.

Pes planus after tibial osteotomy.

When 100 patients who had had a high tibial osteotomy for monocompartmental arthritis were reviewed, 15 were found to have evidence of neurological impairment. A severe symptomatic pes planus deformity of the ipsilateral limb had developed in 4 patients within months of surgery. Electromyographic results showed evidence of dysfunction in the territory of the posterior tibial nerve in all 4 patients, and, in 3 there was evidence of deep peroneal nerve damage. All had surgery for varus malalignment.