Editorial Commentary: Physical Therapy Alone May Not Successfully Treat Patients With Hip Pain and Large α Angles or Decreased Femoral Anteversion Combined With Femoroacetabular Impingement Syndrome.

Understanding the relation between spinopelvic (lumbopelvic) tilt and femoracetabular impingement syndrome (FAIS) is complex, and determining the optimal patient parameters that lead to successful nonoperative management is vital. Physical therapy (PT) focusing on core and posterior chain strengthening is often successful. PT can change the posterior tilt of the pelvis by 5° to 10°, allowing increased range of motion (ROM) and decreased impingement of the hip. However, PT does not change cam anatomy. Thus, PT alone may not sufficiently increase ROM in patients with cam-type impingement and large α angles or limited femoral anteversion. Pelvic compensation may lead to successful nonoperative management of FAIS, but not in all patients. Large-cam, high-flexion athletes with chronic hip pain should try PT. Yet, while some patients with large cam lesions may improve without surgery if femoral version and/or pelvic tilt ROM can be increased, surgery should not be excessively delayed in patients with poor prognostic factors for nonoperative management.

Editorial Commentary: The Addition of the Pericapsular Nerve Group Block Leads to Reduced Pain Up to 24 Hours After Hip Arthroscopy.

Surgeons performing hip arthroscopy (HA) continue to look for solutions to address immediate postoperative pain and achieve a safe and efficient same-day discharge. Multiple studies have looked at modalities to achieve this, and we have learned that some methods are successful whereas others have a high-risk profile and should be avoided. The pericapsular nerve group (PENG) block is at the forefront of the literature. The PENG block is an easy-to-perform pericapsular nerve block that has been shown in prospective and retrospective studies to decrease acute postoperative pain. With modern ultrasound techniques, the PENG block has a short learning curve and acceptable patient safety profile. Other regional blocks have been extensively studied and are not without their drawbacks. Neuraxial anesthesia has shown decreased pain after HA but carries the risk of neuraxial complications and ambulatory discharge delay. Quadratus lumborum, lumbar plexus, and femoral nerve blocks can impact muscle strength and carry the risk of falls. Fascia iliaca blocks have shown the potential for increased pain and have been abandoned. The PENG block has been shown to be safe, but there are risks of inadvertent femoral nerve block if the probe or needle is out of plane. The PENG block does not seem to be the only answer to controlling post-HA pain but is one more weapon in our armamentarium to treat acute postoperative pain. Our current multimodal HA protocol consists of intravenous ketorolac, a PENG block, general endotracheal anesthesia, 4 mg of dexamethasone, 25 mg of ketamine at induction and 25 mg of ketamine slowly infused throughout the case, and post-free HA. We have a 100% same-day discharge rate, with no reported block complications and no groin complications, and for us, this method has proved to decrease the time to discharge.

Claw Toe Deformity After Revision Hip Arthroscopy with Concomitant Periacetabular Osteotomy: A Case Report.

CASE: A 22-year-old woman underwent revision right hip arthroscopy (HA) with concomitant periacetabular osteotomy (PAO). The total procedure time was 5.5 hours. After completion of the 3 hour HA portion, the traction boots were loosened. Eleven weeks postoperatively, she developed a left claw toe deformity. After failed conservative management, she underwent lengthening of the left flexor hallucis longus and flexor digitorum longus tendons. CONCLUSION: This is a case of a claw toe deformity after revision right HA with concomitant PAO. The possibility of this complication should be considered in cases with prolonged intraoperative times because of the use of traction boots.

Comparison of the PROMIS and iHOT-12 in Determining Satisfaction Levels After Hip Arthroscopy for FAIS.

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) has not been fully evaluated for outcomes assessment after hip arthroscopy to correct femoroacetabular impingement syndrome (FAIS). Purpose/Hypothesis: The purpose of this study was to compare the accuracy of the PROMIS Physical Function (PF) and Pain Interference (PI) subscales with the 12-Item International Hip Outcome Tool (iHOT-12) to define patients with 3 unique substantial clinical benefit (SCB) scores-patients who reported ≥80%, ≥90%, and 100% satisfaction at 1 year after hip arthroscopy for FAIS. We hypothesized that the iHOT-12 would be more accurate than the PROMIS-PF and PROMIS-PI subscales in identifying these 3 patient groups. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: We reviewed the records of patients who underwent hip arthroscopy for symptomatic FAIS at 3 centers from January 2019 through June 2021 and had 1-year clinical and radiographic follow-up data. Patients completed the iHOT-12, PROMIS-PF, and PROMIS-PI on initial assessment and at 1 year (±30 days) postoperatively. Postoperative satisfaction was reported on an 11-category scale with anchors defined as "0% satisfied" and "100% satisfied." Receiver operator characteristic analysis was performed to determine the absolute SCB values for the iHOT-12 and PROMIS subscales that would most accurately identify those patients who reported ≥80%, ≥90%, and 100% satisfaction. Area under the curve (AUC) values and 95% CIs for the 3 instruments were compared. Results: Included were 163 patients (111 [68%] women and 52 [32%] men), with a mean age of 26.1 years. Corresponding absolute SCB scores for patients who reported ≥80%, ≥90%, and 100% satisfaction were as follows: iHOT-12, 68.4, 72.1, 74.7; PROMIS-PF, 45, 47.7, 49.9; and PROMIS-PI, 55.9, 52.4, 51.9. The AUC ranged between 0.67 and 0.82, with overlapping 95% CIs indicating a minimal difference in accuracy between the 3 instruments. Sensitivity and specificity values ranged between 0.61 and 0.82. Conclusion: The PROMIS-PF and PROMIS-PI subscales were as accurate as the iHOT-12 in defining absolute SCB scores for patients reporting ≥80%, ≥90%, and 100% satisfaction at 1-year follow-up after hip arthroscopy for FAIS.

Addition of Pericapsular Nerve Group and Transversus Abdominis Plane Blocks Significantly Reduces Opioid Use in Patients Undergoing Concomitant Hip Arthroscopy and Periacetabular Osteotomy.

INTRODUCTION: Previous studies have evaluated the effect of the pericapsular nerve group block for hip arthroscopy and the transverse abdominis plane block for periacetabular osteotomy and have shown decreased narcotic consumption in both groups. No published study has evaluated the effectiveness of combining the blocks when performing hip arthroscopy and periacetabular osteotomy under the same general anesthesia. It was hypothesized that patients treated for hip dysplasia with hip arthroscopy and concomitant periacetabular osteotomy using a pericapsular nerve group block, transverse abdominis plane block, and general anesthesia would have decreased postoperative pain and require less narcotic consumption than those undergoing the procedure with general anesthetic alone.  Methods: A single surgeon performed a retrospective analysis of consecutive patients undergoing concomitant hip arthroscopy and periacetabular osteotomy between 11/2020 and 6/2021. Fifteen consecutive patients undergoing the procedure with a general anesthetic alone (no-block group) were compared to 15 patients undergoing the same procedure with a combined pericapsular nerve group block, transverse abdominis plane block, and general anesthetic (block group). Hip arthroscopy was performed utilizing a post-free technique, and a rectus sparing approach was used for the periacetabular osteotomy. The nerve blocks were performed by multiple anesthesiologists using previously published methods. Operating room time, length of stay, visual analog scale pain scores, and total narcotic consumption in morphine milliequivalents were analyzed. Groups were compared using the chi-squared test for non-continuous demographic variables and a two-tailed t-test for continuous variables utilizing Microsoft Excel (Microsoft, Redmond, WA, USA), p-value set at 0.05 for significance.  Results: The no-block group consisted of 14 females and one male, while the block group was all females. No significant differences were observed between age, sex, BMI, surgery time, length of stay, or procedures performed, p>0.05. The maximal visual analog scale score in the post-anesthesia care unit was 8 ± 1.3 vs. 7 ± 1.9 in the no-block vs. block groups, respectively, p=0.15. The average hospital floor visual analog scale score was 5.7 ± 1.3 vs. 4.8 ± 1.3 in the no-block vs. block groups, respectively, p=0.07. Total pain medications required were 217.6 ± 54.6 vs. 154 ± 41.9 morphine milliequivalents in the no-block vs. block groups, respectively, p=0.001. No complications were reported in either group, and no patient in the block group demonstrated motor nerve palsy or postoperative fall. CONCLUSION:  This study demonstrated that patients undergoing combined hip arthroscopy and periacetabular osteotomy for symptomatic acetabular dysplasia who had pericapsular nerve group, transverse abdominal plane block, and general anesthesia required fewer narcotics in the first 24 hours after surgery compared to those who had general anesthesia alone.

Editorial Commentary: Excessive Femoral Retroversion and Increased Femoral Anteversion Has a Negative Effect on Hip Arthroscopy Outcomes: Symptomatic Extremes of Version Require an Osteotomy.

With the rise in the prevalence of hip arthroscopy, patient selection and proper surgical execution are key to achieving excellent outcomes. As our understanding of femoral acetabular impingement grows, so does our surgical indications to achieve excellent surgical outcomes. Some impingement pathologies are amenable to arthroscopy alone and those with excessive version, dysplasia, Perthese, protrusio, and coxa-vara, or valga require an isolated or combined osteotomy. The version of the femur is known to be a significant source of impingement, and its impact on arthroscopic surgical outcomes has long been assumed to be inconsequential. Those that perform open and arthroscopic hip surgery understand this to be untrue, and arthroscopy alone cannot solve all of our impingement problems.

Multiligament Knee Reconstruction of the ACL, PLC, and ALL in a Floating Knee: A Case Report.

Introduction: Ipsilateral fracture of the femur and tibia, known by the moniker "floating knee," is a serious injury that primarily results from high-energy trauma. Up to 53% of patients with floating knee injuries have concurrent ligamentous injuries, with the anterior cruciate ligament (ACL) as the most commonly affected ligament. Approximately 10% of multi-ligament knee injuries consist of injuries to both the ACL and posterolateral corner (PLC); however, the literature reporting the management of this patient population is sparse, particularly, with a lack of consensus on the timing and protocol of surgical treatment. Well-characterized treatment guidelines are needed for patients with concomitant floating knee and multi-ligament knee injuries. Case Report: A 26-year-old, previously healthy male involved in a high-speed motor vehicle collision presented with upper and lower extremity, skull, and facial fractures, sacropelvic dissociation, and epidural hematoma. Here we describe a rare instance of a floating knee with a multi-ligament knee injury treated through early reconstruction of the ACL, PLC, and anterolateral ligament following stabilization of long bone fractures. Post-injury day 18, the patient underwent single-stage reconstruction of his multi-ligament knee injury. The timing of this was chosen to allow for capsular scar formation to aid in arthroscopy. Conclusion: Our surgical algorithm consists of allograft reconstruction using an all-inside ACL technique and a modified anatomical PLC technique. We recommend early (1-3 weeks) surgical treatment of multi-ligament knee injuries for patients without a closed head injury; however, an individualized treatment approach should be sought, considering the severity of ligamentous injuries, pre-injury activity level, extent of soft-tissue damage, and the activity goals of the patient post-injury. In patients with floating knee injuries, the proposed surgical algorithm here may be utilized for successful multi-ligament knee injury reconstruction.

Editorial Commentary: Degeneration of Acetabular Cartilage of any Degree Is a Predictor of Worse Outcome After Hip Arthroscopy for Labral Repair and Femoroacetabular Impingement Syndrome: The Greater the Damage, the Worse the Outcome.

As the volume of hip arthroscopy continues to rise, determining appropriate indications for the procedure is of paramount importance. Outcomes can be predicted based on well-powered studies focused on determining which patients meet thresholds for achieving the minimal clinically important difference, the patient acceptable symptomatic state, and substantial clinical benefit after treatment. Recent research has shown that acetabular cartilage damage predicts lesser outcomes, and the more advanced the damage, the worse the results. What is concerning is that even the smallest degree of chondromalacia with fibrillation is a negative predictor of achieving the patient acceptable symptomatic state. In contrast, greater than 3 mm of joint space, no cysts, no dysplasia, younger age, lower alpha angle, preoperative 12-item International Hip Outcome Tool score greater than 48.5, and proper version all predict significant improvement after hip arthroscopy.

Computer Navigation vs. Conventional Overlay Methods in Direct Anterior Total Hip Arthroplasty: A Single Surgeon Experience.

BACKGROUND:  The use of computer navigation (CN) is expanding in direct anterior (DA) total hip arthroplasty (THA). In this study, we investigated the use of a noninvasive, fluoroscopic-based, CN technology suite on operative outcomes in a single surgeon DA THA practice. HYPOTHESIS: Computer-navigated DA THA decreases leg length discrepancy (LLD) variation and fluoroscopic radiation dose without adding operative time compared to the traditional overlay (OL) technique. METHODS: A retrospective review was performed on a total of 109 primary DA THA patients, with 58 in the CN and 51 in the OL group. Outcome metrics were postoperative LLD, radiation dose per case, and operative time. Statistical analysis was completed with Mann-Whitney U tests for differences between the means for LLD, radiation dose, and operative time. RESULTS: No difference was observed in postoperative LLD between the CN (average: 1.8 mm) and OL (average: 1.9 mm) groups (p = 0.458). A significant reduction in average radiation dose (mGy) per case within the CN group (8.17 ± 6.09 mGy) compared to the OL group (13.17 ± 7.75 mGy) (p < 0.02) was observed. The average operative time in the CN group was 80 ± 18 minutes compared to 120 ± 32 minutes in the OL group (p < 0.01). CONCLUSION: There was no difference in LLD between the two groups. The addition of CN into a DA THA practice decreased both average radiation dose and operative time when compared to the standard OL technique.

Preoperative Pericapsular Nerve Group Block Results in Less Pain, Decreased Narcotic Use, and Quicker Discharge Time Than No Block in Patients Who Were Surgically Treated for Femoroacetabular Impingement Syndrome.

Purpose: To determine the effectiveness of pericapsular nerve group (PENG) block for patients surgically treated for femoroacetabular impingement syndrome (FAIS). Methods: Consecutive patients who underwent surgical treatment of FAIS either with or without preoperative PENG block by a single surgeon were retrospectively identified. Twenty-five patients who received PENG block were matched 1:1 by age, sex, body mass index, and procedure to 25 patients who received no block (NB). A retrospective review of the medical records of consecutive patients undergoing the PENG block was performed. Outcome measures of postanesthesia care unit visual analog scale initial (PACU VAS-initial), maximum (PACU VAS-max), discharge (PACU VAS-discharge), intraoperative fentanyl, pain medications in morphine equivalents (ME), and PACU to discharge times were recorded. Results: Twenty-five patients undergoing a PENG block and 25 patients who did not undergo a block (NB) were identified. No significant differences observed between age, sex, body mass index, surgery time, or procedures performed between the PENG and NB groups, P > .05. Significantly less VAS-initial was observed in the PENG group 3.7 ± 3.2, versus 5.5 ± 2.9 in the NB group, P = .04. Fentanyl usage intraoperatively was 137.3 ± 53.3 µg versus 108.5 ± 39.6 µg in NB versus PENG group respectively, P = .04. Narcotic use was 50.29 ± 11.2 ME versus 34.3 ± 12.1 ME in NB versus PENG group respectively, P = .001. PACU to discharge time was 95.8 ± 31 minutes versus 81.5 ± 19 minutes in NB versus PENG group, respectively, P = .05. No patient in the PENG group demonstrated a motor nerve palsy. Conclusions: For patients undergoing hip arthroscopy for FAIS, the addition of a preoperative PENG block showed a significant decrease in initial PACU pain, PACU narcotic consumption, intraoperative fentanyl usage, and quicker time to discharge without complications when compared to a no block, post-free control group. Level of Evidence: III, retrospective cohort study.

Arthroscopic and Endoscopic Treatment of Proximal Rectus Femoris Avulsion.

Proximal rectus femoris avulsion (PRFA) is an uncommon injury that is poorly reported in the literature. Historically, these injuries have been treated nonoperatively or with open techniques. This is the first study showing endoscopic treatment of this injury. We present a systematic review of PRFA treatment and a case report of a patient whose injury was treated endoscopically. Sixty-four injuries were reported across several sports. Patients underwent nonoperative management, suture repair, suture anchor repair, or excision of the tendon stump. Surgical complications included lateral femoral cutaneous nerve injury and wound complications. The patient who underwent arthroscopic treatment had a good outcome. [Orthopedics. 2022;45(1):e1-e6.].

Post-Related Complications in Hip Arthroscopy Are Reported Significantly Greater in Prospective Versus Retrospective Literature: A Systematic Review.

PURPOSE: To determine whether there are differences in (1) the incidence of post-related complications following hip arthroscopy between prospective and retrospective publications; and (2) between post-assisted and postless techniques. METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to characterize post-related complications following hip arthroscopy for central or peripheral compartment hip pathology, including femoroacetabular impingement syndrome and chondrolabral injury. Inclusion criteria were prospective and retrospective Level I-IV evidence investigations that reported results of hip arthroscopy performed in the supine position. Exclusion criteria included open or extra-articular endoscopic hip surgery. Post-related complications included pudendal nerve injury (sexual dysfunction, dyspareunia, perineal pain or numbness) or perineum/external genitalia soft-tissue injury. RESULTS: Ninety-four studies (12,212 hips; 49% male, 51% female; 52% Level IV evidence) were analyzed. Prospective studies (3,032 hips) report a greater incidence of post-related complications compared with retrospective (8,116 hips) studies (7.1% vs 1.4%, P < .001). Three studies (1,064 hips) used a postless technique and all reported a 0% incidence of pudendal neurapraxia or perineal soft tissue injury. Most pudendal nerve complications were transient, resolving by 3 months, but permanent nerve injury was reported in 4 cases. Only 19%, 22%, 7%, and 4% of studies reported a total surgery time, traction time, traction force, and bed Trendelenburg angle for their study samples, respectively. CONCLUSIONS: The incidence of post-related complications is 5 times greater in prospective (versus retrospective) hip arthroscopy literature. Postless distraction resulted in a 0% incidence of post-related injuries. LEVEL OF EVIDENCE: IV, systematic review of Level I-IV evidence.

Editorial Commentary: Post-Free Arthroscopy Reduces Complications and Pain: To Post or Not to Post? Is That Still a Question?

Post-free hip arthroscopy has garnered much attention over the past several years. The attraction of eliminating groin complications is at the forefront of this technique. Recent studies have shown improved blood flow, safe techniques, but other benefits, if any, are yet to be discovered. For now, those adopting post-free distraction do so to eliminate a source of groin complication, improved access to the cam, and a perceived decrease in pain. Several options exist to achieve post-free distraction, and, as we continue to perfect this technique, continued studies may reveal other advantages or disadvantages to post removal.

A Novel Radiographic Finding of Intracapsular Heterotopic Ossification: A Report of Two Cases.

Symptomatic heterotopic ossification (HO) is a complication of hip arthroscopy that occurs in less than 1% of cases. To our knowledge, there are no reported cases of symptomatic intracapsular HO. We present 2 patients with a radiographic finding associated with intracapsular HO. Both patients underwent revision hip arthroscopy and required capsular reconstruction due to void of the iliofemoral ligament following excision of HO. We believe this radiographic finding may be useful to hip preservationists as it may be associated with capsular deficiency necessitating capsular reconstruction upon revision hip arthroscopy.

Editorial Commentary: Patient-Reported Outcomes Measurement Information System (PROMIS) Has Decreased Disease-Specific Responsiveness More Than Legacy Outcome Measures, But PROMIS and Legacy Measures Do Correlate: You Can't Have Your Cake and Eat It Too.

A better understanding of hip-preservation patients lies in our ability to analyze and collect data. Collecting the appropriate outcome measures is required to improve treatments, personalize health care, and drive policy. Current research suggests legacy measures and Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used in data collection, but which measures are best? PROMIS computer-adaptive tests are an attractive outcome measure source because they allow for low-burden data capture with reduced completion times and limited floor and ceiling effects. PROMIS provides numerous reliable, sensitive, and domain-specific measurements capturing a patient's health outcomes. PROMIS has been shown to correlate with hip and other legacy outcome measures, but because PROMIS is more general than some legacy measures, it may be less responsive. PROMIS measures are applicable across a wide spectrum of health measures for our patients, including hip femoroacetabular impingement, but should not replace the legacy measure of the International Hip Outcome Tool 12. However, PROMIS should still be measured because it may allow greater comparison to studies of other conditions resulting in diminished reporting bias.

Validation of Self-Reported Smoking Status Among Orthopedic Hip Surgery Patients.

Purpose The purpose of this study was to determine the accuracy of self-reported non-smoking status in subjects undergoing elective orthopedic surgery as confirmed by serum cotinine levels. Methods Institutional Review Board approval was obtained for this retrospective review of consecutive subjects that underwent elective orthopedic surgery by a single fellowship-trained orthopedic surgeon. All patients provided smoking history (active, former, or non-smoker). Serum cotinine levels defined each subject as "non-smoker", "passive tobacco exposure", or "active smoker". Self-reported non-smokers were eligible for inclusion. Subjects were excluded if they failed to provide smoking history, reported themselves as "smokers", and/or had unavailable serum cotinine levels. Self-reported non-smoking status accuracy was determined by dividing the total number of included subjects by the number of subjects that were defined as "non-smoker" or "passive tobacco exposure" on their serum cotinine test. Results A total of 378 patients (mean age of 42.5 (13-78) years and 68% female) self-reported as non-smokers and were included. A total of 369 subjects had serum cotinine levels consistent with "non-smoking" resulting in a self-reported non-smoking status accuracy of 97.6%. None of the former smokers had cotinine levels consistent with active smoker status. Conclusion Subjects undergoing elective orthopedic surgery self-report as non-smokers with an accuracy of 97.6%. This suggests that routine serum cotinine testing of non-smokers in this patient population may not be necessary.

Editorial Commentary: Hip Hypotrophic Labrum Should Not Change Our Treatment Algorithm: Welcome to the Augmented Reality of the Hip-Preservation Zone.

Current treatment for labral pathology continues to be of some debate; debride, repair, or reconstruct. There are many factors hip preservationists consider when treating the labrum, and the size of the labrum is one. Some feel that small labral tissue with tears cannot function as well as larger tissue when repaired, and others feel that all labrum need removed and reconstructed in a primary setting. This conundrum leads us to continued research to define the best practices in hip preservation.

Pseudotumor Caused by a Retained Intra-articular Bullet: A Case Report.

CASE: A 54-year-old man presented with systemic lead poisoning due to a gunshot wound to the hip suffered 35 years prior to presentation. He urgently underwent removal of the bullet with total hip arthroplasty and was found to have a pseudotumor. This case highlights the team-based approach to manage systemic lead poisoning caused by an intra-articular bullet. CONCLUSION: We report on the first documented case of systemic lead toxicity and a pseudotumor caused by an intra-articular bullet. An expeditious, team-based approach is necessary for appropriate treatment. Our treatment algorithm can guide future teams on the management of this reversible disorder.

Editorial Commentary: Quantifying Patient Satisfaction After Hip Arthroscopy: I Cannot Deactivate Until You Are Satisfied With Your Care.

The evolution of hip-preservation research is now streamlining toward evaluating our results as they relate to minimal clinically important difference, patient acceptable symptomatic state and substantial clinical benefit and less to P value-only significance. The keystone to successful hip-preservation procedures lies in proper patient selection, expert surgical execution, following results, and measuring satisfaction over time. Having a truly objective measure for establishing patient satisfaction is paramount to guiding surgical success.

A comparison of leg length discrepancy between direct anterior and anterolateral approaches in total hip arthroplasty.

BACKGROUND: Leg length discrepancy (LLD) after total hip arthroplasty (THA) is a known source of complications and a leading cause of litigation (J Bone Joint Surg Br 87:155-157, 2005). There are limited studies investigating surgical approach combined with the use of fluoroscopy intraoperatively and their potential effects on LLD after THA. The purpose of this study was to compare the direct anterior (DA) approach utilizing a fluoroscopic overlay technique and anterolateral (AL) approach and their potential effect on LLD. METHODS: We retrospectively reviewed 121 patients who had undergone primary THA from September 1, 2016 to November 1, 2018 by either DA or AL approach by two separate surgeons. Leg length discrepancies were measured on pre-operative post-anesthesia care unit (PACU) and on post-operative low anterior/posterior (AP) pelvis plain radiographs by two investigators blinded to each other's measurements. To confirm inter-observer and intra-observer reliability between LLD measurements amongst investigators, a Pearson correlation test was performed. The primary outcome measurement was leg length discrepancy (LLD). RESULTS: We observed LLD > 1.0 cm and LLD > 1.5 cm in the DA and AL groups. The DA approach group showed a mean LLD of 4.5 mm against 7.76 mm in the AL group (p < 0.00001). There was a significantly higher rate of LLD in the AL group as compared to the DA group (LLD> 1 cm (28% vs. 8%, p = 0.0037) and LLD > 1.5 cm (7% vs. 0%, p = 0.0096). The LLD measurements showed strong correlation in terms of inter-observer (r = 0.95) and intra-observer reliability (r = 0.99) between the two investigators (p < 0.001). CONCLUSION: In our patient cohort, the DA approach with fluoroscopic overlay technique had less LLD in comparison with the AL approach, suggesting that intraoperative fluoroscopic use does have an impact on LLD.