A propensity score-matched analysis on the impact of patient and surgical factors on early periprosthetic joint infection in minimally invasive anterolateral and transgluteal total hip arthroplasty.

INTRODUCTION: Increased risk of periprosthetic joint infection (PJI) in minimally invasive (MIS) total hip arthroplasty (THA) is still debated. This study aimed to identify differences in surgical and patient-related risk factors for PJI between an MIS anterolateral approach and transgluteal-modified Hardinge approach. METHODS: A retrospective cohort of 5315 THAs performed between 2006 and 2019 at a single institution was screened. Short stem THAs performed via an MIS anterolateral approach in the supine position and standard straight stem THAs performed via a transgluteal modified Hardinge approach were included. Propensity score matching was performed to control for selection bias. After matching, 1405 (34.3%) short stem THAs implanted via MIS anterolateral approach and 2687 (65.7%) straight stem THAs implanted via a transgluteal modified Hardinge approach were included. The risk of PJI due to patient-specific and surgical factors was retrospectively analyzed using chi-square test and multivariate regression analysis. RESULTS: PJI occurred in 1.1% in both MIS anterolateral and transgluteal approach (p = 0.823). Multivariate regression showed an increased infection risk for patients with a BMI between 35 and 39.99 kg/m2 (OR 6.696; CI 1.799-24.923; p = 0.005), which could not be demonstrated for transgluteal approach (OR 0.900; CI 0.900-4.144; p = 0.93). A BMI ≥ 40 kg/m2 (OR 14.150; CI 2.416-82.879; p = 0.003) was detected as a risk factor for PJI only in anterolateral approach. Increased operation time ≥ 121 min showed a significantly increased risk for PJI in the general cohort (OR 6.989; CI1.286-37.972; p = 0.024). CONCLUSION: Minimally invasive anterolateral and transgluteal THA show a comparable rate of early PJI within the first year of index surgery. A BMI of ≥ 35 kg/m2 was detected as a clear risk factor for infection in the anterolateral approach. Prolonged operation time ≥ 121 min increases the risk of PJI regardless of approach.

DIFFERENCE IN PATIENT QUALITY OF LIFE AFTER HIP ARTHROPLASTY WITH A MINIMALLY INVASIVE APPROACH OR CLASSIC APPROACH.

The increasing rate of orthopedic procedures, hip arthroplasty in particular, requires improvement of surgical techniques, as well as of the respective rehabilitation protocols. The aim of the study was to assess differences in the quality of life and incidence of limping eight years after total hip arthroplasty performed with a minimally invasive or classic approach. This cross-sectional study included 68 patients, i.e. 32 operated with classic approach and 36 with minimally invasive approach during 2011. The following parameters were observed: anthropometric measurements, history of comorbidity, subjective assessment of limping, and SF-36 questionnaire (Short Form Survey Instrument). SF-36 testing, which consists of 8 domains, showed that 5 domains of the quality of life were statistically significantly better in the minimally invasive group (level of significance p<0.05). These domains were role of limitation due to physical health (p=0.01), energy (p=0.02), social functioning (p=0.02), pain (p=0.02) and general health (p=0.00). The minimally invasive group had a statistically significantly lower incidence of limping (p=0.032). Quality of life after hip replacement could be a decisive factor when choosing the type of orthopedic procedure. The higher number of limping patients in the classic approach group may have contributed to differences in the quality of life. In conclusion, the minimally invasive approach enables higher long-term quality of life and functional recovery.

Transgluteal versus prone approach to extracorporeal shockwave lithotripsy for patients with distal ureteral stones: A systematic review and meta-analysis.

To explore the effectiveness of transgluteal approach during extracorporeal shockwave lithotripsy (ESWL) for patients with distal ureteral stones compared to the prone approach. A systematic literature search was carried out by two reviewers independently on the basis of three electronic databases up to Aug. 2020. Three randomized controlled trials (RCT) and one cohort studies (CS), with a total of 516 patients, comparing transgluteal approach with prone approach during ESWL for distal ureteral stones were included. The methodological quality of RCT was evaluated by Cochrane collaboration's tools, and the quality of CS and CCS was evaluated by modified Newcatle-Ottawa scale. The weighted mean difference (WMD) and odds ratio (OR) was respectively used to describe results of continuous and dichotomous variables. Pooled data showed that transgluteal approach could significantly improve the rate of stone free after the first treatment [OR = 3.18, 95% confidence interval (CI) 2.19-4.63, p < 0.00001] and the rate of overall stone free (OR = 4.03, 95% CI 2.43-6.69, p < 0.00001). In addition, compared with the prone approach, the transgluteal one could also significantly reduce the rate of ureteroscopy (OR = 0.21, 95% CI 0.12-0.36, p < 0.00001). What's more, complications were rarely reported, which demonstrated a similar safety for two approaches. Our study suggested that, during ESWL for patients with distal ureteral stones, transgluteal approach was a safe and more effective choice than the prone position.

68Ga-PSMA PET/CT targeted biopsy for the diagnosis of clinically significant prostate cancer compared with transrectal ultrasound guided biopsy: a prospective randomized single-centre study.

PURPOSE: 68Ga-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) is valuable for detecting primary and recurrent prostatic lesions. This study aimed to evaluate the efficacy of 68Ga-PSMA-11 PET/CT as a triage tool for prostate biopsy (PSMA-TB) and compare with transrectal ultrasound-guided biopsy (TRUS-GB) for the diagnosis of clinically significant prostate cancer (csPCa). METHODS: This single-centre study randomly allocated 120 patients with elevated serum prostate-specific antigen (PSA) levels (> 4 ng/ml) to PSMA-PET or TRUS group. Patients with PSMA-avid lesions (SUVmax ≥ 8.0) underwent PSMA-TB via a single-puncture percutaneous transgluteal approach (n = 25), whilst patients with negative PSMA-PET underwent systematic TRUS-GB (n = 35). All patients in the TRUS group underwent TRUS-GB directly (n = 60). RESULTS: PCa and csPCa were detected in 26/60 (43.3%) and 24/60 (40.0%) patients in the PSMA-PET group and 19/60 (31.6%) and 15/60 (25.0%) in the TRUS group, respectively. In the PSMA-PET group, the detection rate of PCa and csPCa were significantly higher in PSMA-PET-positive than negative patients (PCa, 23/25 (92.0%) vs 3/35 (8.6%), P < 0.01; csPCa, 22/25 (88.0%) vs 2/35 (5.7%), P < 0.01). PSMA-TB detected significantly more PCa and csPCa than TRUS-GB in the TRUS controls (PCa, 21/25 (84.0%) vs 19/60 (31.6%), P < 0.01; csPCa, 20/25 (80.0%) vs 15/60 (25.0%), P < 0.01). PSMA-PET detected significantly more cases of csPCa amongst patients with PSA 4.0-20.0 ng/ml than TRUS (27.02% vs 8.82%, P < 0.05). No haematuria, urinary retention or pelvic infection was observed after PSMA-TB compare with TRUS-GB. CONCLUSIONS: 68Ga-PSMA-11 PET/CT is a feasible imaging technique that may serve as a triage tool for prostate biopsy, and may improve the detection rate of csPCa compared with TRUS-GB, especially in patients with serum PSA 4.0-20.0 ng/ml.

A prospective randomized comparison of the minimally invasive direct anterior and the transgluteal approach for primary total hip arthroplasty.

BACKGROUND: The presented prospective randomized controlled single-centre study compares the clinical outcome up to 12 months after total hip arthroplasty using a minimally invasive single-incision direct anterior (DAA) and a direct transgluteal lateral approach. METHODS: A total of 123 arthroplasties were evaluated utilizing the Harris Hip Score (HHS), the extra short musculoskeletal functional assessment questionnaire (XSFMA), the Short Form 36 (SF-36) health survey, a Stepwatch™ Activity Monitor (SAM), and a timed 25 m foot walk (T25-FW). Postoperative x-ray images after THA were reviewed to determine inclination and stem positioning. RESULTS: At final follow-up, the XSFMA functional index scores were 10.3 (anterior) and 15.08 (lateral) while the bother index summed up to a score of 15.8 (anterior) and 21.66 (lateral) respectively, thus only differing significantly for the functional index (p = 0.040 and p = 0.056). The SF-36 physical component score (PCS) was 47.49 (anterior) and 42.91 (lateral) while the mental component score (MCS) summed up to 55.0 (anterior) and 56.23 (lateral) with a significant difference evident for the PCS (p = 0.017; p = 0.714). Patients undergoing THA through a DAA undertook a mean of 6402 cycles per day while those who had undergone THA through a transgluteal approach undertook a mean of 5340 cycles per day (p = 0.012). Furthermore, the obtained outcome for the T25-FW with 18.4 s (anterior) and 19.75 s (lateral) and the maximum walking distance (5932 m and 5125 m) differed significantly (p = 0.046 and p = 0.045). The average HHS showed no significant difference equaling 92.4 points in the anterior group and 91.43 in the lateral group (p = 0.477). The radiographic analysis revealed an average cup inclination of 38.6° (anterior) and 40.28° (lateral) without signs of migration. CONCLUSION: In summary, our outcomes show that after 1 year THA through the direct anterior approach results in a higher patient activity compared to THA utilizing a transgluteal lateral approach while no differences regarding hip function are evident. TRIAL REGISTRATION: DRKS00014808 (German Clinical Trial Register DRKS); date of registration: 31.05.2018.

A new endoscopic minimal invasive approach for pudendal nerve and inferior cluneal nerve neurolysis: An anatomical study.

AIM: To describe a new minimal invasive approach of the gluteal region which will permit to perform neurolysis of the pudendal and cluneal nerves in case of perineal neuralgia due to an entrapment of these nerve trunks. METHOD: Ten transgluteal approaches were performed on five cadavers. Relevant anatomic structures were dissected and further described. Neurolysis of the pudendal nerve or cluneal nerves were performed. Landmarks for secure intraoperative navigation were indicated. RESULTS: The first operative trocar for the camera was inserted with regards to the iliac crest in the deep gluteal space. With the aid of pneumodissection, the infragluteal plane was dissected. The piriformis muscle was identified as well as the sciatic and the posterior femoral cutaneous nerve. Consequently, the sciatic tuberosity was visualized together with the cluneal nerves. Hereafter, the second trocar was introduced caudal to the first one and placed on an horizontal line passing at the level of the coccyx, allowing access to the ischial spine and the visualization of the pudendal nerve and vessels. A third 5 mm trocar was then inserted medial from the first one, permitting to dissect and transsect the sacrospinous ligament. The pudendal nerve was subsequently transposed and followed on its course in the pudendal channel. CONCLUSIONS: A reliable exploration of the gluteal region including identification of the sciatic, pudendal, and posterior femoral cutaneous nerves is feasible using a minimal invasive transgluteal procedure. Consequently, the transposition of the pudendal nerve and the liberation of the cluneal nerves can be performed.

Surgical Approaches for Total Hip Arthroplasty.

Total hip arthroplasty (THA) has become one of the most reliable and patient-requested surgical interventions in all medicine. The procedure can be performed using a variety of surgical approaches, but the posterior approach, direct lateral approach, and direct anterior approach are by far the most common across the globe. This article highlights the history and technique for each of these common approaches. A review of outcomes and complications for each approach are also provided. Each approach has its own unique advantages and disadvantages, but all can be safely and successful utilized for THA. Strong, convincing, high-quality studies comparing the different approaches are lacking at this time. Surgeons are therefore recommended to choose whichever approach they are most comfortable and experienced using. Though not described here, THA can also be done using the anterolateral approach (also known as the Watson Jones approach) as well as the two-incision approach. In addition, recently, some surgeons are utilizing the so-called direct superior approach for THA. While these approaches are far less commonly utilized, they are recognized as viable alternatives to traditional approaches.

Entrapment of the posterior femoral cutaneous nerve and its inferior cluneal branches: anatomical basis of surgery for inferior cluneal neuralgia.

PURPOSE: The apparent failure of pudendal nerve surgery in some patients has led us to suggest the possibility of entrapment of other adjacent nerve structures, leading to the concept of inferior cluneal neuralgia. Via its numerous collateral branches, the posterior femoral cutaneous nerve innervates a very extensive territory including the posterior surface of the thigh, the infragluteal fold, the skin over the ischial tuberosity, but also the lateral anal region, scrotum or labium majus via its perineal branch. METHODS: We described the pathophysiological features of cluneal neuralgia, the surgical technique and our preliminary results. RESULTS: We performed a transmuscular approach leading to the fat of the deep gluteal region. Exploration was continued cranially underneath the piriformis, looking for potential entrapments affecting the posterior femoral cutaneous nerve and the sciatic nerve. Nerve decompression on the lateral surface of the ischial tuberosity was then performed. A constant anatomical finding must be highlighted: the presence of a lateral fibrous expansion from the ischium passing behind the nerves and vessels, especially the posterior femoral cutaneous nerve and its perineal branches. In our patients, release of this expansion allowed decompression of the nerve trapped by this expansion. CONCLUSION: Cluneal neuralgia constitutes a distinct entity of perineal pain, which must be identified and distinguished from pudendal neuralgia. Surgery should be performed via a transgluteal approach. A lateral ischial obstacle must be investigated, in the form of a constant fibrous expansion, which, like a retinaculum, can cause nerve entrapment.

Risk of infection in primary, elective total hip arthroplasty with direct anterior approach or lateral transgluteal approach: a prospective cohort study of 1104 hips.

BACKGROUND: The direct anterior approach (DAA) is increasingly popular for hip replacement. However, the small incision and the location near to the groin might increase the risk of periprosthetic joint infection (PJI). We asked the questions (i) whether there is an increased risk of infection for this approach, and (ii) whether the spectrum of microorganisms differs between patients with DAA and those with lateral transgluteal approach (LAT). METHODS: All patients operated between 08/2006 and 12/2013 were followed prospectively in an in house register. The DAA was introduced as routine in 02/2009 at our hospital. Patients with primary elective hip replacement without previous operations were included. Follow-up was scheduled after 6, 12 weeks and 1, 2 years. PJI was defined according to standardized criteria. RESULTS: One thousand one hundred four patients were studied, 700 were operated with DAA and 404 with LAT. No patient was lost to follow-up. PJI was diagnosed in 23/1104 (2.1 %) patients, 16 (2.3 %) in the group with DAA, and 7 (1.7 %) in the group with LAT. Patients with infection had a higher BMI (p < 0.001) and a higher ASA score (p < 0.001). Only patients with the DAA had exogenous PJI caused by gramnegative bacilli (35.7 % vs 0 %, p = 0.26). In the DAA-group, the fraction of patients with polymicrobial infection was somewhat higher than in the LAT-group (50 % vs 33 %, P = 0.64). CONCLUSION: There was no increased risk of infection for the DAA.

Comparative retrospective study of the direct anterior and transgluteal approaches for primary total hip arthroplasty.

PURPOSE: The presented retrospective study compares clinical outcomes five years after total hip arthroplasty performed through a minimally invasive direct anterior approach and a direct transgluteal lateral approach. METHODS: A total of 171 arthroplasties in 167 patients were evaluated utilizing the Harris hip score (HHS), the SF-36, a daily activity questionnaire, and the UCLA activity score. RESULTS: The average HHS showed no significant difference equalling 91.4 points in the anterior group and 92.4 in the lateral group (p = 0.952). The SF-36 physical component scores were 50.7 (anterior) and 50.0 (lateral) while the psychometric properties added up to 48.6 (anterior) and 50.3 (lateral) with no significant differences evident (p = 0.782, p = 0.071). Daily activity was found to result in 4,855 (anterior) and 5,016 (lateral) cycles, respectively (p = 0.364). No difference regarding pain sensation was determined (p = 0.859). A significant difference was found for the UCLA score, which was calculated to be 5.9 in the anterior and 6.4 in the lateral approach group (p = 0.008). CONCLUSION: In summary, our mid-term results show comparable outcomes for both approaches regarding functionality, pain, quality of life and daily activity.

Changes in gait patterns and muscle activity following total hip arthroplasty: a six-month follow-up.

BACKGROUND: Appropriate gait function is an important determinant of the outcome of total hip arthroplasty and relies on appropriate joint motion and muscle activity. The purpose of this study was to test the hypothesis that 6-month postoperative dynamic joint range of motion, time-distance measures and muscle activity in the operated limb in patients undergoing total hip arthroplasty differ from preoperative levels and are more similar to those observed postoperatively in the contralateral limb and in healthy subjects. METHODS: Basic time-distance gait measurements, knee and hip kinematics and electromyographic activity from eight hip muscles were obtained preoperatively and 6 months postoperatively in 52 patients undergoing total hip arthroplasty and in 24 age-matched healthy subjects during treadmill walking. FINDINGS: Postoperative dynamic hip range of motion for the operated limb (confidence interval differences [-3.9°; -2.3°]) and postoperative knee range of motion for both limbs (operated: [-8.4°; -5.6°]; contralateral: [-8.1°; -5.3°]) in patients with total hip arthroplasty were significantly lower than values for the control subjects (P<0.001). Postoperative gait in patients with total hip arthroplasty was more symmetric than preoperative gait. Preoperative and postoperative electromyographic intensities were higher in patients with total hip arthroplasty than values for the control subjects (P<0.001), and patients had different EMG patterns compared to the control group. INTERPRETATION: Pre- and postoperative differences not only in hip but also in knee kinematics emphasize the importance of evaluating the dynamic outcome of total hip arthroplasty by assessing joint motion of all lower extremity joints in both legs.

Exposure of the sciatic nerve in the gluteal region without sectioning the gluteus maximus: Analysis of a series of 18 cases.

BACKGROUND: Dissecting through the gluteus maximus muscle by splitting its fibers, instead of complete sectioning of the muscle, is faster, involves less damage to tissues, and diminishes recovery time. The objective of the current paper is to present a clinical series of sciatic nerve lesions where the nerve was sufficiently exposed via the transgluteal approach. METHODS: We retrospectively selected 18 traumatic sciatic nerve lesions within the buttock, operated upon from January 2005 to December 2009, with a minimum follow-up of 2 years. In all patients, a transgluteal approach was employed to explore and reconstruct the nerve. RESULTS: Ten males and eight females, with a mean age of 39.7 years, were studied. The etiology of the nerve lesion was previous hip surgery (n = 7), stab wound (n = 4), gunshot wound (n = 3), injection (n = 3), and hip dislocation (n = 1). In 15 (83.3%) cases, a motor deficit was present; in 12 (66.6%) cases neuropathic pain and in 12 (66.6%) cases sensory alterations were present. In all cases, the transgluteal approach was adequate to expose the injury and treat it by neurolysis alone (10 cases), neurolysis and neurorrhaphy (4 cases), and reconstruction with grafts (4 cases; three of these paired with neurolysis). The mean pre- and postoperative grades for the tibial nerve (LSUHSC scale) were 1.6 and 3.6, respectively; meanwhile, for the peroneal division, preoperative grade was 1.2 and postoperative grade was 2.4. CONCLUSIONS: The transgluteal approach adequately exposes sciatic nerve injuries of traumatic origin in the buttock and allows for adequate nerve reconstruction without sectioning the gluteus maximus muscle.