Intra-operative referencing technique is non-inferior to use of fluoroscopy for acetabular component positioning in anterior hip arthroplasty.

BACKGROUND: Intra-operative fluoroscopy has been shown to improve the accuracy of acetabular component positioning when compared to no fluoroscopy in direct anterior approach (DAA) total hip arthroplasty (THA). Due to logistical reasons, our senior author has been performing DAA THA at one institution without the use of fluoroscopy and has created an intraoperative referencing technique to aid in acetabular component positioning. The purpose of this study is to evaluate the accuracy of acetabular component positioning using fluoroscopy when compared to an intra-operative referencing technique without fluoroscopy. METHODS: A total of 214 consecutive primary DAA THA were performed by one surgeon at two institutions and were retrospectively reviewed over a 3-year period. Intra-operative fluoroscopy was used with all patients at Institution A (N = 154). At institution B (N = 60), no fluoroscopy was used, and an intra-operative referencing technique was employed to assist in placement of the acetabular component. RESULTS: In the fluoroscopy group, 91% of components met our abduction target, 90% met our anteversion target, and 82.5% simultaneously met both targets. In the non-fluoroscopy group, 98% of components met our abduction target, 92% met our anteversion target, and 90% simultaneously met both targets. There was no difference between groups for placement of the component within both targets simultaneously (p = .171). CONCLUSION: Use of our intra-operative referencing technique is non-inferior in placing acetabular components within a pre-defined safe zone when compared to use of intraoperative fluoroscopy. The intra-operative reference technique can be a helpful adjunct for ensuring accurate acetabular component positioning while simultaneously reducing cost and limiting radiation exposure.

Proximal Tibial Reconstruction After Tumor Resection: A Systematic Review of the Literature.

BACKGROUND: The proximal part of the tibia is a common location for primary bone tumors, and many options for reconstruction exist following resection. This anatomic location has a notoriously high complication rate, and each available reconstruction method is associated with unique risks and benefits. The most commonly utilized implants are metallic endoprostheses, osteoarticular allografts, and allograft-prosthesis composites. There is a current lack of data comparing the outcomes of these reconstructive techniques in the literature. METHODS: A systematic review of peer-reviewed observational studies evaluating outcomes after proximal tibial reconstruction was conducted, including both aggregate and pooled data sets and utilizing a Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) review for quality assessment. Henderson complications, amputation rates, implant survival, and functional outcomes were evaluated. RESULTS: A total of 1,643 patients were identified from 29 studies, including 1,402 patients who underwent reconstruction with metallic endoprostheses, 183 patients who underwent reconstruction with osteoarticular allografts, and 58 patients who underwent with reconstruction with allograft-prosthesis composites. The mean follow-up times were 83.5 months (range, 37.3 to 176 months) for the metallic endoprosthesis group, 109.4 months (range, 49 to 234 months) for the osteoarticular allograft group, and 88.8 months (range, 49 to 128 months) for the allograft-prosthesis composite reconstruction group. The mean patient age per study ranged from 13.5 to 50 years. Patients with metallic endoprostheses had the lowest rates of Henderson Type-1 complications (5.1%; p < 0.001), Type-3 complications (10.3%; p < 0.001), and Type-5 complications (5.8%; p < 0.001), whereas, on aggregate data analysis, patients with an osteoarticular allograft had the lowest rates of Type-2 complications (2.1%; p < 0.001) and patients with an allograft-prosthesis composite had the lowest rates of Type-4 complications (10.2%; p < 0.001). The Musculoskeletal Tumor Society (MSTS) scores were highest in patients with an osteoarticular allograft (26.8 points; p < 0.001). Pooled data analysis showed that patients with a metallic endoprosthesis had the lowest rates of sustaining any Henderson complication (23.1%; p = 0.009) and the highest implant survival rates (92.3%), and patients with an osteoarticular allograft had the lowest implant survival rates at 10 years (60.5%; p = 0.014). CONCLUSIONS: Osteoarticular allograft appears to lead to higher rates of Henderson complications and amputation rates when compared with metallic endoprostheses. However, functional outcomes may be higher in patients with osteoarticular allograft. Further work is needed using higher-powered randomized controlled trials to definitively determine the superiority of one reconstructive option over another. In the absence of such high-powered evidence, we encourage individual surgeons to choose reconstructive options based on personal experience and expertise. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of Isolated Lateral Malleolus Fractures.

Isolated lateral malleolus fractures represent one of the most common injuries encountered by orthopaedic surgeons. Nevertheless, appropriate diagnosis and management of these injuries are not clearly understood. Ankle stability is maintained by ligamentous and bony anatomy. The deep deltoid ligament is considered the primary stabilizer of the ankle. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. The most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. Clinical examination findings are important but less reliable. Advanced imaging may not be accurate for guiding management. If the ankle is stable, nonsurgical management produces excellent outcomes. In the case that clinical/radiographic findings are indicative of ankle instability, surgical fixation options include lateral or posterolateral plating or intramedullary fixation. Locking plates and small or minifragment fixation are important adjuncts for the surgeon to consider based on individual patient needs.

Surgical approaches to the calcaneus and the sural nerve: There is no safe zone.

BACKGROUND: Sural nerve related symptoms following the extensile lateral approach to the calcaneus (ELA) and the sinus tarsi approach (STA) are a known postoperative complication despite awareness of the course the sural nerve. While the main trunk of the sural nerve and its location relative to the approaches have been previously described, the nerve gives rise to lateral calcaneal branches (LCBs) and an anastomotic branch (AB) that may be at risk of injury. The purpose of this study was to describe the course of the sural nerve, its LCBs and the AB in relation to the ELA and STA. METHODS: 17 cadaveric foot specimens were dissected, exposing the sural nerve, the LCBs and the AB. A line representing the ELA and STA incision was then created. It was noted if the line crossed the sural nerve trunk, any of the LCBs, and the AB, and at what distance they were crossed using the distal tip of the fibula as a reference. RESULTS: The sural nerve was identified in all specimens, and the main trunk was noted to cross the path of the ELA in no specimens and the path of the STA in 2 (12%) specimens. At least one LCB of the sural nerve was identified in all specimens. The ELA crossed the path of at least one LCB in 15 specimens (88%). An AB was present in 9 specimens (53%). If an AB was present, this was crossed by the STA in every instance. CONCLUSIONS: The ELA and the STA traverses the path of either the main trunk of the sural nerve, the LCBs, or the AB in the majority of specimens, potentially accounting for the presence of sural nerve postoperative symptoms regardless of the approach used.