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.

Comparison of conjoined tendon-preserving posterior approach and conventional posterolateral approach in hemiarthroplasty for femoral neck fracture in the elderly: A multicenter (TRON group) retrospective study.

BACKGROUND: Femoral neck fractures (FNF) are one of the most common traumatic injuries in the elderly. The conjoined tendon-preserving posterior (CPP) approach was developed as a modification of the conventional posterolateral (PL) approach in hemiarthroplasty (HA) for displaced femoral neck fractures (FNF) to reduce postoperative dislocation. We hypothesized that the CPP approach would result in fewer dislocations and similar functional and radiographic outcomes compared to the PL approach. PATIENTS AND METHODS: This was a retrospective multicenter (TRON group) study. We evaluated the rate of complications, and functional and radiographic outcomes for patients aged >65 years who underwent HA via the PL approach or the CPP approach from 2017 to 2019 and followed up for at least 24 months. To adjust for baseline differences between the groups, a propensity score-matching algorithm was used in a 1:1 ratio. RESULTS: We identified 135 patients who underwent HA via the PL approach and 135 patients via the CPP approach. The mean follow-up period was 32.4 ± 14.0 months. The incidence of dislocation was 6 in 135 patients (4.4%) in the PL group and 0 in 135 patients (0%) in the CPP group, and there was significant difference (p = 0.04). Operation time was equivalent between the two groups (73.1 ± 30.4 vs. 71.8 ± 30.0 min; p = 0.72). The rate of varus insertion of stems in the PL group lower than that in the CPP group (19.3% vs. 33.3%; p = 0.01). Postoperative Parker's mobility score was similar between the two groups at 12 months follow-up (6.17 vs. 6.27; p = 0.81). CONCLUSION: The CPP approach showed a significantly lower dislocation rate, similar functional outcome and more varus stem insertions compared with the PL approach in this retrospective study.

Surgeons Experience Greater Physiologic Stress and Strain in the Direct Anterior Approach Than the Posterior Approach for Total Hip Arthroplasty.

INTRODUCTION: The direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) have advantages and disadvantages, but their physiologic burden to the surgeon has not been quantified. This study was conducted to determine whether differences exist in surgeon physiological stress and strain during DAA in comparison to PA. METHODS: We evaluated a prospective cohort of 144 consecutive cases (67 DAA and 77 PA). There were five, high-volume, fellowship-trained arthroplasty surgeons who wore a smart-vest that recorded cardiorespiratory data while performing primary THA DAA or PA. Heart rate (beats/minute), stress index (correlates with sympathetic activations), respiratory rate (respirations/minute), minute ventilation (liters/min), and energy expenditure (calories) were recorded, along with patient body mass index and operative time. Continuous data was compared using T-tests or Mann Whitney U tests, and categorical data was compared with Chi-square or Fischer's exact tests. RESULTS: There were no differences in patient characteristics. Compared to PA, performing THA via DAA had a significantly higher surgeon stress index (17.4 versus 12.4; P < 0.001), heart rate (101 versus 98.3; P = 0.007), minute ventilation (21.7 versus 18.7; P < 0.001), and energy expenditure per hour (349 versus 295; P < 0.001). However, DAA had a significantly shorter operative time (71.4 versus 82.1; P = 0.001). CONCLUSION: Surgeons experience significantly higher physiological stress and strain when performing DAA compared to PA for primary THA. This study provides objective data on energy expenditure that can be factored into choice of approach, case order, and scheduling preferences, and provides insight into the work done by the surgeon.

Total Corpus Callosotomy via Posterior Approach with Endoscopic-Alone Technique.

Two main surgical techniques are available for corpus callosotomy (CC): conventional microscopic CC and endoscopic CC.1 Microscopic CC is more familiar to neurosurgeons and allows three-dimensional visualization, but it requires a larger craniotomy and has a narrower visual angle in the deep part. Endoscopic CC has only recently been introduced to epilepsy surgery, but it is gaining increasing interest among epilepsy surgeons. The endoscope provides two-dimensional visualization and requires a camera as an additional instrument inserted into the surgical corridor. The merits of endoscopic CC include the smaller craniotomy and smaller skin incision, potentially reducing invasiveness.2 Bridging veins to the superior sagittal sinus are also less problematic because of the reduced need for brain retraction. The lack of need of arachnoid dissection is another advantage. Generally, an anterior approach is applied for CC, but this approach makes interhemispheric fissure dissection mandatory, especially at the cingulate gyri. In some cases, this procedure can take a long time. On the other hand, a posterior approach requires less interhemispheric arachnoid dissection, or sometimes none at all, due to the anatomy of the falx cerebri. These reasons have driven the development of a posterior approach for an endoscopic-alone technique.3 Here, we present a 5-year-old girl with medically intractable epileptic spasms that were diagnosed as infantile epileptic spasms syndrome, who underwent endoscopic total CC via a posterior approach to control her seizures (Video 1).

Comparison of Early Postoperative Step and Stair Counts With the Direct Anterior Approach Versus the Posterior Approach for Total Hip Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the impact of direct anterior approach (DAA) or posterior approach (PA) on step and stair counts after total hip arthroplasty using a remotely monitored mobile application with a smartwatch while controlling for baseline characteristics. METHODS: This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform. The primary outcomes were step and stair counts and changes from baseline through one year. Step and stair counts were available for 1,501 and 847 patients, respectively. Longitudinal regression models were created to control for baseline characteristics. RESULTS: Patients in the DAA group had significantly lower body mass index (P = .049) and comorbidities (P = .028), but there were no significant differences in age (P = .225) or sex (P = .315). The DAA patients had a higher average and improvement from baseline in step count at 2 and 3 weeks postoperatively after controlling for patient characteristics (P = .028 and P = .044, respectively). The average stair counts were higher for DAA patients at one month postoperatively (P = .035), but this difference was not significant after controlling for patient demographics. Average stair ascending speeds and changes from baseline were not different between DAA and PA patients. Descending stair speed was higher at 2 weeks postoperatively for DAA patients, but was no longer higher after controlling for baseline demographics. CONCLUSIONS: After controlling for baseline characteristics, DAA patients demonstrate earlier improvement in step count than PA patients after total hip arthroplasty. However, patient selection and surgeon training may continue to influence outcomes through a surgical approach.

Is open anterior advantageous to posterior decompression and reconstruction in fresh A3 to C3/AO type thoracolumbar junction fractures? A systematic review.

INTRODUCTION: Surgical outcomes of open anterior and open posterior approaches, for thoracolumbar A3 to C3/AO type fractures, are compared. METHODS: A PubMed search was conducted from 1990 to 2024 related to anterior, posterior, and combined approaches. Inclusion criteria: Fresh traumatic T10 to L2 fractures, age ≥13 years, ≥10 cases, minimum follow-up 6 months. Exclusion criteria: Cadaveric studies, pathological fractures, reviews, thoracoscopy-assisted, mini-open lateral (MOLA) and minimal invasive anterior or posterior approaches. Coleman Methodology Scores (CMS) (modified for spinal trauma) indicated potential selection bias in the selected studies. PRISMA guidelines were adapted. RESULTS: Nineteen studies with 847 participants were selected. The average CMS quality score was fair. The anterior approach, although it better decompresses the compromised spinal canal, it is also associated with increased surgical complications compared to the posterior approach. The neurological outcome, the loss of correction and the reoperation rate, were similar to both approaches. This systematic review favors posterior approach. CONCLUSIONS: The anterior approach is demanding and is associated with a higher rate of surgical complications compared to the posterior approach. The limitations of the selected studies included inconsistence in the: 1) approaches selection, 2) classifications of the fracture types and the neurological status and 3) variety of instrumentations used. PROSPERO ID: CRD42023484222.

Abdominal Arterial Translation in Lower Lumbar Spine Level Due to Positional Change: A Clinical Survey Using Intraoperative Computed Tomography.

Background: Abdominal vascular injury, a fatal complication of lumbar disc surgery, should concern spine surgeons. This study aimed to compare the position of the abdominal arteries in the supine and prone positions and the factors involved. Thirty patients who underwent lumbar surgery by posterior approach were included. Methods: All patients underwent computed tomography (CT) preoperatively in the supine position and intraoperatively in the prone position. In the CT axial image, at the L4, L4/5 disc, L5, and L5/S1 disc level, we measured the shortest distance between the abdominal arteries and the vertebral body (SDA: shortest distance to the aorta), and the amount of abdominal arterial translation, defined as "SDA on intraoperative CT" minus "SDA on preoperative CT". Additionally, the preoperative CT axial images were evaluated for the presence of aortic calcification. Results: No significant difference in SDA values based on patients' positions was observed at each level. In males, the supine position brought the abdominal artery significantly closer to the spine at the left side of the L5/S level (p = 0.037), and, in cases of calcification of the abdominal artery, the abdominal artery was found to be closer to the spine at the left side of the L4/5 level (p = 0.026). Conclusions: It is important to confirm preoperative images correctly to prevent great vessel injuries in lumbar spine surgery using a posterior 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.

Treatment of bilateral Posterior Tibial Compartment Syndrome using a Novel Surgical Approach: A Case Report of the Posterior Approach.

Osteofascial compartment syndrome is a serious surgical emergency that requires prompt diagnosis and treatment. It presents a challenge for surgeons due to its high disability rate and difficult management. Early fasciotomy decompression is crucial in preventing severe complications. Classic fasciotomy approaches for tibial osteofascial compartment syndrome include double-incision and single-incision techniques.This paper presents a case of a 24-year-old female with bilateral tibial posterior compartment syndrome resulting from prolonged squatting after alcohol intoxication, which is a relatively rare mechanism. We employed an innovative posterior approach to manage the patient with tibial posterior compartment syndrome. Ultimately, we successfully preserved the patient's legs and achieved a good functional recovery.The paper reported a rare case with bilateral posterior tibial compartment syndrome resulting from squatting for 10 hours after alcohol intoxication. The patient achieved favorable outcomes in lower limb function following treatment with a new fasciotomy approach, the posterior approach.The new approach for treating posterior tibial compartment syndrome can serve as a valuable reference for surgeons.

Characteristics and Quality of Online Searches for Direct Anterior Versus Posterior Approach for Total Hip Arthroplasty.

BACKGROUND: Online resources are important for patient self-education and reflect public interest. We described commonly asked questions regarding the direct anterior versus posterior approach (DAA, PA) to total hip arthroplasty (THA) and the quality of associated websites. METHODS: We extracted the top 200 questions and websites in Google's "People Also Ask" section for 8 queries on January 8, 2023, and grouped websites and questions into DAA, PA, or comparison. Questions were categorized using Rothwell's classification (fact, policy, value) and THA-relevant subtopics. Websites were evaluated by information source, Journal of the American Medical Association Benchmark Criteria (credibility), DISCERN survey (information quality), and readability. RESULTS: We included 429 question/website combinations (questions: 52.2% DAA, 21.2% PA, 26.6% comparison; websites: 39.0% DAA, 11.0% PA, 9.6% comparison). Per Rothwell's classification, 56.2% of questions were fact, 31.7% value, 10.0% policy, and 2.1% unrelated. The THA-specific question subtopics differed between DAA and PA (P < .001), specifically for recovery timeline (DAA 20.5%, PA 37.4%), indications/management (DAA 13.4%, PA 1.1%), and technical details (DAA 13.8%, PA 5.5%). Information sources differed between DAA (61.7% medical practice/surgeon) and PA websites (44.7% government; P < .001). The median Journal of the American Medical Association Benchmark score was 1 (limited credibility, interquartile range 1 to 2), with the lowest scores for DAA websites (P < .001). The median DISCERN score was 55 ("good" quality, interquartile range 43 to 65), with the highest scores for comparison websites (P < .001). Median Flesch-Kincaid Grade Level scores were 12th grade level for both DAA and PA (P = .94). CONCLUSIONS: Patients' informational interests can guide counseling. Internet searches that explicitly compare THA approaches yielded websites that provide higher-quality information. Providers may also advise patients that physician websites and websites only describing the DAA may have less balanced perspectives, and limited information regarding surgical approaches is available from social media resources.

Posterior-only 2-level vertebrectomy and fusion in a medically complex patient with lumbar metastasis: illustrative case.

BACKGROUND: Spinal metastases are commonly seen in patients with cancer and often indicate a poor prognosis. Treatment can include curative or palliative surgery, chemotherapy, and radiation therapy. The surgical approach varies widely on the basis of the affected region of the spine, the location of the tumor (anterior versus posterior), the goal of surgery, the health of the patient, and surgeon preference. OBSERVATIONS: The authors present a case of a 68-year-old male with intractable lower-back pain and substantially diminished ambulation. Diagnostic imaging revealed a lumbar metastasis from a cholangiocarcinoma primary at L2-3 (4.5 cm anteroposterior × 5.7 cm transverse × 7.0 cm craniocaudal). The patient underwent a 2-level vertebrectomy with expandable cage placement and T10 to S2 fusion via a posterior-only approach. The patient regained much of his mobility and quality of life after the surgery. LESSONS: Although this was a high-risk surgery, the authors show that a posterior-only approach can be used for lumbar vertebrectomies and fusion when necessary. Palliative surgeries carrying a high risk, especially in the setting of a limited prognosis, should include multidisciplinary deliberations and a thorough discussion of the risks and outcome expectations with the patient.

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.

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.

Functional and Radiological Outcomes of All-Posterior Surgical Correction of Dystrophic Curves in Patients with Neurofibromatosis Type 1.

STUDY DESIGN: A retrospective cohort study. PURPOSE: To determine outcomes following all-posterior surgery using computed tomography navigation, hybrid stabilization, and multiple anchor point techniques in patients with neurofibromatosis type 1 (NF-1) and dystrophic scoliosis. OVERVIEW OF LITERATURE: Previous studies favored antero-posterior fusion as the most reliable method; however, approaching the spine anteriorly was fraught with significant complications. With the advent of computer assisted navigation and multiple anchor point method, posterior only approach is reporting successful outcomes. METHODS: This study included patients who underwent all-posterior surgical deformity correction for dystrophic NF-1 curves. Coronal and sagittal Cobbs angles, apical rotation, and the presence of dystrophic features were evaluated before surgery. Postoperatively, sagittal, coronal, and axial correction, implant position, and implant densities were evaluated. The decline in curve correction and implant-related complications were evaluated at follow-up. Clinical outcomes were evaluated using the Scoliosis Research Society-22 revised index. RESULTS: This study involved 50 patients with a mean age of 13.6 years and a mean follow-up duration of 5.52 years. With a mean coronal flexibility of 18.7%, the mean apical vertebral rotation (AVR), preoperative coronal Cobb angle, and sagittal kyphosis were 27.4°, 64.01°, and 47.70°, respectively. The postoperative mean coronal Cobb angle was 30.17° (p <0.05), and the sagittal kyphosis angle was 25.4° (p <0.05). The average AVR correction rate was 41.3%. The correction remained significant at the final mean follow-up, with a coronal Cobb angle of 34.14° and sagittal kyphosis of 25.02° (p <0.05). The average implant density was 1.41, with 46% of patients having a high implant density (HID). The HID had a markedly higher mean curve correction (29.30° vs. 38.05°, p <0.05) and a lower mean loss of correction (5.7° vs. 3.8°, p <0.05). CONCLUSIONS: Utilizing computer-assisted navigation, hybrid instrumentation, and multiple anchor point technique and attaining high implant densities, this study demonstrates successful outcomes following posterior-only surgical correction of dystrophic scoliosis in patients with NF-1.

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.

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.

A Unique Case Of A Giant Popliteal Artery Aneurysm Presenting As Popliteal Mass.

INTRODUCTION: Popliteal artery aneurysms (PAA) can be very challenging, especially in cases of very large PAAs, with a minimal number of case reports published in the literature. METHODS: This is a case report of a 68-year-old male patient with hypertension, hyperlipidemia, diabetes, and schizophrenia who was found to have a giant (10x8x6cm) partially thrombosed PAA, treated with interposition polytetrafluoroethylene (PTFE) graft via a posterior approach. RESULTS: Under general anesthesia, the patient was placed in a prone position, and an extended lazy "S" incision was made on the popliteal fossa. After obtaining proximal and distal exposure, the aneurysm sac was skeletonized, preserving the popliteal vein and the tibial nerve. After proximal and distal control was obtained, the patient was systemically heparinized, and the aneurysm sac was opened. Some genicular branches were ligated inside the aneurysm, and part of the aneurysm sac was excised. A 7 mm PTFE graft was used for reconstruction in an end-to-end fashion. Suction drains were placed in the popliteal space, and the fascia and skin were approximated. The patient was discharged home on the 2nd postoperative day on aspirin and statin with ultrasound surveillance. The patient has remained asymptomatic during follow-up with a patent graft. CONCLUSIONS: Open surgical repair constitutes the gold standard of care for huge PAAs to prevent distal thromboembolic events and mass pressure effects from the aneurysm. Documentation of additional experience with open repair of huge PAAs would be beneficial and could help clinical decision-making.

The Comparison of Posterior Intervertebral Release Combined with Posterior Column Osteotomy and Posterior Column Osteotomy Alone for the Treatment of Moderate-to-Severe Rigid Scoliosis: A Prospective Controlled Study.

OBJECTIVES: There is no consensus on the treatment of moderate-to-severe rigid scoliosis. Anterior release and three-column osteotomy are excessively traumatic, whereas posterior column osteotomy (PCO) alone results in poor outcomes. An emerging surgical technique, posterior intervertebral release (PR), can release the rigid spine from the posterior approach. This study was performed to compare the multi-segment apical convex PR combined with PCO and PCO alone in patients with moderate-to-severe rigid scoliosis. METHODS: From June 2021 to June 2022, this prospective study of moderate-to-severe (Cobb: 70-90°) rigid scoliosis (flexibility of main curve <25%) involved two groups defined by surgical procedure: the PR group, the patients undergoing PR combined with PCO; and the PCO group, the patients undergoing PCO alone. Follow-up was at least 12 months. Radiographic results mainly included main curve Cobb, correction of per PR/PCO segment, apical vertebra rotation (AVR) and apical vertebra translation (AVT). Demographics, surgical data, complications were also recorded. Student's independent samples t test and Pearson's chi-square test were used to compare the differences between groups. RESULTS: Forty patients with an average age of 16.65 years were included (PR group, n = 20; PCO group, n = 20). The main curves averaged 77.56° ± 5.86° versus 78.02° ± 5.72° preoperatively and 20.07° ± 6.73° versus 33.58° ± 5.76° (p < 0.001) at the last follow-up in the PR and PCO groups, respectively. The mean correction rates were 74.30% and 56.84%, respectively (p < 0.001). The average coronal curve correction was 13.49° per release segment, which was significantly higher than the PCO correction of 6.20° (p < 0.001). The correction of apical vertebra rotation and translation in the main thoracic curve was significantly better in the PR group than in the PCO group (p < 0.05). Several minor complications in the two groups improved after conservative treatment. CONCLUSION: The multi-segment apical convex PR combined with PCO offers more advantages than PCO alone in the treatment of patients with moderate-to-severe rigid scoliosis. Owing to its excellent corrective effect and few complications, this is a high benefit-risk ratio surgical strategy for rigid scoliosis.

Comparison of complication rates between anterior versus posterior approaches for treating unstable Hangman's fracture. 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.

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.