Our experience with the surgical management of lower cervical spine fractures: fifty case series.

PURPOSE: Trauma to the lower cervical spine is a serious lesion due to its neurological consequences which jeopardize the vital and functional prognosis. They constitute a public health problem due to their frequency and seriousness requiring rapid and adequate treatment. The aim of our study is to (1) describe the epidemiological, clinical, and radiological characteristics of lower cervical spine trauma patients; (2) support the therapeutic management of these patients and show our experience in surgery for lower cervical spine trauma; and (3) analyze the anatomical and functional results and discuss them with literature data. METHODS: This is a retrospective descriptive study of 50 patients with lower cervical spine trauma treated surgically over a period of five years from January 1, 2016, to December 2020. RESULTS: The average age of our patients was 34.5 years, with a sex ratio of 1.7. The etiologies are dominated by accidents on public roads (58%). They show neurological disorders such as spinal cord damage in 30% of cases and root damage in 20% of cases. The radiological assessment revealed eight tear drops, ten comminuted fractures, 12 severe sprains, 12 biarticular dislocations, six uniarticular dislocations, and two herniated discs. Treatment was surgical in all patients with an anterolateral approach and anterior arthrodesis. The evolution was favourable in 21 patients and stationary in 29 patients. CONCLUSION: Our study concluded that dislocations and fracture dislocations were the predominant type of injury in cases of AVP. Tetraplegia was mainly observed with uni- and biarticular dislocations. The variation in consolidation time was not correlated with trauma-to-surgery time. Better neurological recovery was observed with mild initial neurological damage than with initially severe damage. The appearance of an adjacent syndrome is less frequent with monosegmental arthrodesis than with multisegmental arthrodesis. Cage arthrodesis was an alternative to iliac harvesting with similar results.

Cementless short stem total hip arthroplasty in patients older than 75 years: is it feasible?

BACKGROUND: In recent years, the indication for cementless short stem total hip arthroplasty (THA) has been widened to elderly patients as they might profit by the advantages of the short-curved implant design as well. Therefore, this study was conducted to evaluate the clinical and radiological outcome of a cementless short stem in elderly patients (≥ 75 years) compared to a young control group (≤ 60 years). METHODS: A retrospective cohort of 316 THAs performed between 2014 and 2017 was prospectively examined. In all patients a cementless, curved short stem and press-fit cup (Fitmore® stem; Allofit®/-S cup; both ZimmerBiomet, Warsaw, IN, USA) were implanted via a minimally-invasive anterolateral approach. Clinical and radiological outcome as well as rate of complications and revision were assessed. RESULTS: In total, 292 patients have been included for analysis of complications and revisions (Øfollow-up: 4.5 years) and 208 patients for clinical and radiological outcome (Øfollow-up: 4.4 years). Complication rate was significantly increased in elderly patients (13.7% vs. 5.8%, p = 0.023), while the revision rate was increased without statistical significance (5.2% vs. 2.2%, p = 0.169). Periprosthetic fractures occurred significantly higher in the elderly patients (5.2% vs. 0.7%; p = 0.026). Both groups showed a comparable clinical outcome in the Harris Hip Score (93.7 vs. 91.9; p = 0.224), Oxford Hip Score (44.5 vs. 43.7; p = 0.350), Forgotten Joint Score (81.7 vs. 81.5; p = 0.952) and WOMAC (7.4 vs. 9.3; p = 0.334). CONCLUSION: Cementless short stem total hip arthroplasty shows a comparable clinical and radiological outcome in patients over 75 years of age compared to younger patients under 60 years of age. However, cementless shorts stem THA shows an increased rate of overall complications and periprosthetic fractures in elderly patients over 75 years of age. Cemented fixation of the femoral component should be considered in patients over 75 years of age. LEVEL OF EVIDENCE: III Case-controlled study. TRIAL REGISTRATION: Observational study without need for trial registration due to ICMJE criteria.

Influence of greater trochanteric bone density and three-dimensional morphology on perioperative greater trochanteric fracture following total hip arthroplasty via an anterolateral approach.

BACKGROUND: Perioperative greater trochanteric fracture following total hip arthroplasty (THA) using the anterolateral approach is a recognized perioperative complication. There was no previous study to determine the relationship between bone mineral density (BMD) and three-dimensional greater trochanter morphology for perioperative greater trochanter fractures. The purpose of this study is to identify the influence of greater trochanteric bone density and three-dimensional morphology on perioperative greater trochanteric fracture following THA using the anterolateral approach. METHODS: We investigated 209 hips done primary THA using the anterolateral approach and preoperative BMD test for the proximal femoral bone with a minimum of 6 months follow-up. We picked up all patients who had perioperative greater trochanteric fractures. Multivariate analysis was done in order to investigate the influence of the greater trochanter young adult mean (YAM) and three-dimensional morphology on perioperative greater trochanteric fractures. RESULTS: There were 10 joints (10/209, 4.8%) with perioperative greater trochanteric fractures. Osteosynthesis was required only in one joint (1/209, 0.5%) because the bone fragments were significantly displaced proximally by the gluteus medius. Multivariate analysis showed the combination of Type B femoral shape (in cases where the top of the great trochanter was inside the longitudinal central axis of the planned femoral stem in computed tomography (CT)- based three-dimensional templating) and a YAM of < 80% was the only risk factor for fracture. CONCLUSIONS: The preoperative greater trochanter BMD test (YAM < 80%) and three-dimensional femoral morphology (Type B femoral shape) provide useful information to mitigate the occurrence of perioperative greater trochanter fractures associated with THA using the anterolateral approach.

Anterolateral (juxtacondylar) approach with limited mastoidectomy to resect a jugular foramen meningioma.

BACKGROUND: The anterolateral (juxtacondylar) approach with limited mastoidectomy is a suitable option to expose the postero-inferior part of the jugular foramen (JF). It is particularly indicated for tumors extending in the neck beyond the jugular foramen, especially in those cases necessitating both neck control as well as control of the mastoid segment of facial nerve. METHOD: We describe here the steps to safely perform an anterolateral approach with mastoidectomy along with a brief description of its indications and limits. CONCLUSION: This approach represents a valid option to reach the JF. Its knowledge can improve the process of optimal approach selection when dealing with complex pathology involving the JF.

Anterolateral versus posterolateral decompression and spinal stabilization in thoracolumbar Potts spine: a comparative study.

AIM: To assess and compare the clinical, radiological, and functional outcomes of anterolateral and posterolateral decompression and spinal stabilization in the thoracolumbar tuberculous spine. MATERIAL AND METHODS: 30 patients with thoracolumbar spinal tuberculosis were treated surgically between September 2014 and 2018. Fifteen patients underwent anterolateral decompression and spinal stabilization from September 2014 to September 2016. These patients were studied retrospectively (group A). Fifteen patients underwent posterolateral decompression by costotransversectomy and spinal stabilization from September 2016 to September 2017 were studied prospectively. Neurological recovery, correction of kyphotic deformity, pain (visual analog score) and ESR, and duration of stay were assessed. Neurological outcome was assessed using Frankel grading, and pain was assessed using visual analog scale. RESULTS: The average follow-up period in both the groups is 12 months. There was a statistically significant difference in the kyphotic angle correction between anterolateral and posterolateral groups at the end of 12 months (follow up). No statistically significant difference was found between the two groups for ESR, visual analog scale for pain, and neurological recovery (Frankel's grading) at the end of 12 months. CONCLUSION: Both anterolateral and posterolateral approaches are sufficient thoracic and thoracolumbar tuberculous spine but, the posterolateral approach allows a significant correction of kyphotic angle, better improvement of pain and lesser duration of stay.

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.

Risk factor analysis on perioperative greater trochanteric fracture of total hip arthroplasty via anterolateral approach.

INTRODUCTION: A greater trochanteric fracture is a perioperative complication of primary total hip arthroplasty (THA) via an anterolateral approach. Although surgeons determine risk factors in the preoperative planning phase, no study explored the relationship between the planned femoral implant and greater trochanter. This study attempts to determine the risk factors for perioperative greater trochanteric fractures in primary THA via an anterolateral approach. MATERIALS AND METHODS: This retrospective single-institution study enrolled 440 patients (66 males and 374 females) who underwent primary THA via an anterolateral approach with a minimum follow-up of six months. First, we selected patients with perioperative greater trochanteric fractures, regardless of the need for additional surgery. Second, we investigated the risk factors for perioperative greater trochanteric fractures using the patients' demographic data, operative data, and femoral geometry data via univariate and multivariate analyses. RESULTS: Perioperative greater trochanteric fractures occurred in 30 joints (30/440, 6.8%), and all cases were reported in women. Multivariate analysis revealed that in cases where the top of the great trochanter was inside the longitudinal central axis of the planned femoral stem in three-dimensional templating (Type B) was the only independent risk factor for perioperative greater trochanteric fracture (odds ratio, 14.6; 95% confidence interval, 5.88-36.1; P < 0.001). CONCLUSION: This study identified female sex and Type B femoral geometry as risk factors for perioperative greater trochanteric fracture via an anterolateral approach. Our results may reduce the incidence of perioperative greater trochanteric fractures associated with primary THA.

Digital templating cementless short stem total hip arthroplasty: is there a difference in planning adherence between the direct anterior approach and minimally invasive anterolateral approach?

PURPOSE: Minimally invasive approaches (MIS) in total hip arthroplasty (THA) show inconsistent findings regarding planning adherence in digital templating. The purpose of this study is to evaluate any difference in planning adherence between the direct anterior approach (DAA) and an anterolateral MIS approach (AL MIS) in cementless short stem THA. METHODS: A single surgeon series of 222 THAs in 208 patients with an uncemented short curved stem and a bi-hemispherical acetabular cup were screened for inclusion. A total of 118 THAs were implanted via the DAA and 72 THAs via the AL MIS were included. The planning adherence for the offset option, stem size and the acetabular cup were retrospectively evaluated. RESULTS: Planning adherence for cup size (perfect match: p = 0.763; ± 1 size: p = 0.124), offset option (0.125) and stem size (perfect match: p = 0.275; ± 1 size: p = 0.552) did not show any statistical significance. Preoperative diagnosis of avascular necrosis of the femoral head in AL MIS approach (OR 6.045; CI 1.153-31.696) or mild hip dysplasia in the general cohort poses (OR 11.789; CI 1.386-100.293) a significant risk for inadequate prediction of the offset option. CONCLUSION: digital templating for THA with an uncemented short curved stem and a bi-hemispherical acetabular cup show comparable results between a direct anterior approach and a minimally invasive anterolateral approach in supine position. Surgeons should be aware of a low planning adherence for this type of short stem in minimally invasive approaches. CONCLUSION: Digital templating for THA with an uncemented short curved stem and a bi-hemispherical acetabular cup show comparable results between a direct anterior approach and a minimally invasive anterolateral approach in supine position. Surgeons should be aware of a low planning adherence for this type of short stem in minimally invasive approaches.

The 'critical trochanter angle' does not show superiority over the CCD angle in predicting varus stem alignment in cementless short-stem total hip arthroplasty.

PURPOSE: Varus positioning of the femoral stem can affect the hip offset (HO). The critical trochanter angle (CTA) was introduced in 2019 as a novel geometric angle, to predict varus stem alignment in cementless straight stem THA. The aim of this study was to evaluate the applicability of the CTA as a predictor for stem alignment in THA with a cementless neck resecting short stem. PATIENTS AND METHODS: In this retrospective study, 106 patients (index surgery 2014-2019) with unilateral THA and a morphologically healthy contralateral hip as a reference (Kellgren-Lawrence ≤ 1) were included. A cementless short stem with meta-diaphyseal fixation and press-fit cup was implanted in all cases. Stem alignment, CCD angle, CTA and offset reconstruction were measured on preoperative and 3 months postoperative AP radiographs of the pelvis. RESULTS: Preoperative lower CTA and lower CCD angle were positively correlated (r = 0.472; p < 0.001). Higher varus stem alignment is correlated with lower CTA (r = - 0.384; p < 0.001) and lower CCD angle (r = - 0.474; p < 0.001). A CTA of 23.1° or lower showed a sensitivity of 59.1% and a specificity of 87.1% (AUC: 0.733) and a CCD angle of 132.75° or lower a sensitivity of 68.2% and a specificity of 80.6% (AUC: 0.77) for a varus stem alignment > 3°. CONCLUSION: The CTA is also applicable in cementless THA with a neck resecting short stem to evaluate risk of intraoperative varus stem positioning. The CCD angle shows higher sensitivity with marginally lower specificity. Therefore, the CTA is not superior in predicting varus stem alignment in short-stem THA. LEVEL OF EVIDENCE: IV.

Learning Curve for Short-Stem Total HIP Arthroplasty through an Anterolateral Approach.

Background and Objectives: Short-stem total hip arthroplasty has become increasingly popular in recent years. While many studies have shown excellent clinical and radiological results, very little is known about the learning curve for short-stem total hip arthroplasty through an anterolateral approach. Therefore, the aim of this study was to determine the learning curve for short-stem total hip arthroplasty among five residents in training. Materials and Methods: We performed retrospective data analysis of the first 30 cases of five randomly selected residents (n = 150 cases) with no experience before the index surgery. All patients were comparable, and several surgical parameters and radiological outcomes were analyzed. Results: The only surgical parameter with a significant improvement was the surgical time (p = 0.025). The changes in other surgical parameters and radiological outcomes showed no significant changes; only trends can be derived. As a result, the correlation between surgical time, blood loss, length of stay, and incision/suture time can also be seen. Only two of the five residents showed significant improvements in all examined surgical parameters. Conclusions: There are individual differences among the first 30 cases of the five residents. Some improved their surgical skills faster than others. It could be assumed that they assimilated their surgical skills after more surgeries. A further study with more than 30 cases of the five surgeons could provide more information on that assumption.

Comparing the Anterior-Based Muscle-Sparing Approach with the Direct Anterior Approach in Hip Arthroplasty: A Systematic Review and Pairwise Meta-Analysis.

Background and Objectives: The anterior-based muscle-sparing (ABMS) approach, which utilizes the interval between the tensor fasciae latae posteriorly, offers several advantages, such as the reduced risk of nerve injury and the freedom to choose various implants. Herein, we aimed to compare the outcome of ABMS to the direct anterior (DA) approach using pairwise meta-analysis techniques. Materials and Methods: A systematic search of the MEDLINE (PUBMED), Embase, and Cochrane Library databases was performed for studies published up to 7 June 2023, which compared the ABMS approach with the DA approach for hip arthroplasty. We compared (1) perioperative outcomes (operation time, visual analog scale (VAS) score, total opioid consumption, length of hospital stay (LOS), and the number of patients discharged to their homes); (2) postoperative complications (neuropraxia/nerve injury, dislocation, surgical site infection, intraoperative fracture, and reoperation rate); and (3) implant position (cup inclination, cup anteversion, and stem alignment). Results: Ten studies were eligible for meta-analysis, including 1737 patients who underwent hip arthroplasty with the ABMS approach and 1979 with the DA approach. The pooled analysis showed no differences in all outcome variables, including perioperative outcomes, postoperative complications, and the implant position between the two surgical approaches. Conclusions: In current meta-analysis, the ABMS approach demonstrated comparable results to the conventional DA approach in terms of both clinical and radiologic outcomes as well as postoperative complications. Furthermore, the ABMS approach has the advantage of a broader indication and fewer limitations in terms of the surgical position compared to the DA approach. Therefore, the ABMS approach can be even more beneficial as an option within MSA, surpassing the utility of the DA approach.

Comparison of prone-supine versus supine position for the treatment of pilon fractures via modified posteromedial approach combined with anterolateral approach.

BACKGROUND: Most of modified posteromedial approaches require prone position for the treatment of pilon fractures. We describe the technique of modified posteromedial approach under supine position. The goal of the study was to compare the radiographic and clinical outcomes of prone-supine versus supine position for the treatment of pilon fractures via modified posteromedial approach combined with anterolateral approach. METHODS: A total of 50 retrospectively consecutive pilon fractures that underwent open reduction internal fixation via modified posteromedial approach combined with anterolateral approach from 2016 to 2019 were reviewed at least a two-year follow up. The positions of patients were divided into two groups: prone-supine versus supine position (26 vs 24, respectively). The operation time, radiographic outcomes including bone union time and ratio of congruent articular reduction were evaluated. The post-operative function was evaluated using the Manchester Oxford score (MOXFQ) and the visual analogue score (VAS). The motion of ankle joint and complications and were also compared. RESULTS: The mean follow-up was 42.2(24.7-73.0) months in the prone-supine group and 42.7(37.3-56.5) months in the supine group (P = .87). The mean operation time was 141.9 ± 10.1 min in the prone-supine group and 107.5 ± 18.9 min in the supine group (P = .00). There was no significant difference in the bone union time and ratio of congruent articular reduction between the two groups. There was no significant difference in the final MOXFQ score, VAS score, and the mean range of ankle motion between the two groups (P > .05). The total incidence of complications was 11.5% in the prone-supine group and 16.6% in the supine group (P = .66). CONCLUSION: The patient in the prone-supine position versus supine position for pilon fractures via modified posteromedial approach combined with anterolateral approach contributed comparable quality of reduction, bone union time functional outcomes and complications. The supine technique was significantly shorter in terms of operation time.

No benefits of minimally invasive total hip arthroplasty via Watson-Jones approach: A retrospective cohort study.

INTRODUCTION: There is controversy about the role of minimally invasive surgery (MIS) for total hip arthroplasty (THA). The present study aimed to investigate whether a MIS approach has a positive impact on the outcome of THA via the Watson-Jones anterolateral approach. Clinical scores and radiological findings of minimally and standard invasive exposures were evaluated and compared. METHODS: The present study was conducted according to the STROBE statement. Patients operated between 2017 and 2018 in two different orthopaedic institutions was performed. Patients with symptomatic coxarthrosis reducing considerably patient's quality of life were asked to participate in the present study. Patients were divided into two THA groups: MIS and standard invasive surgery (SIS). Surgical procedures were performed in by two experienced surgeons via the Watson-Jones approach. RESULTS: Data from 140 patients were collected (70 patients for each group) at two years follow-up. Leg length discrepancy was greater in the MIS cohort (P = 0.01). The Stiffness subscale of the WOMAC score resulted minimally increased in the SIS group (P = 0.03). The overall WOMAC score and the other subscales resulted similar between the two groups. Femoral offset, acetabular offset, cup orientation, cup inclination, VAS resulted similar between the two cohorts. Only a case of revision in the SIS group was reported. CONCLUSION: THA via the Watson-Jones approach achieves short terms excellent results. Surgery performed via a MIS approach does not provide any superior outcome compared to the SIS in terms of radiographic findings and clinical scores at two years follow-up.

Digital templating for the implantation of a curved short hip stem with an anterolateral MIS approach shows gender differences in digital templating.

PURPOSE: Digital templating shows reliable accuracy for straight stem systems. In recent years, the implantation of short stems through minimally invasive approaches has gained more popularity. Minimally invasive approaches (MIS) show the risk of undersizing femoral components. Therefore, we questioned the planning adherence for a curved short stem and a bi-hemispherical acetabular cup implanted through an anterolateral MIS approach. METHODS: A consecutive series of 964 hips (index surgery between 2014 and 2019) with Fitmore® curved short stem and Allofit/-S® acetabular cup (both ZimmerBiomet Inc, Warsaw, IN) were included. Preoperative digital templating was conducted anterior-posterior (AP) digital radiographs of the hip using mediCAD® version 5.1 (Hectec GmbH, Altdorf, Germany). The templates of acetabular and femoral components (offset option and stem size) were retrospectively evaluated for general adherence, and according to sex, BMI and planner's experience. RESULTS: Planning adherence for the exact offset option was 70.6 and 21.6% for exact offset option and stem size. Adherence for acetabular cup ± 1 size was 74.8%. A significant difference between male and female patients for the offset option could be found (p = 0.03, z = -2983). In 22.5% of male patients, an offset option one size higher and in 12.3% of female patients an offset option one size smaller than templated was used intraoperatively CONCLUSION: Digital templating for the Fitmore® stem in cementless THA with a minimally invasive anterolateral approach shows comparable planning adherence to the existing literature for this cementless short stem. However, a lower planning adherence was detected compared to conventional straight stem systems. In male patients, the femoral offset is frequently undersized and in female patients frequently oversized compared to the preoperative plan. Surgeons should be aware of this difficulty in digital templating for Fitmore® hip stem.

Direct anterior approach improves in-hospital mobility following hemiarthroplasty for femoral neck fracture treatment.

INTRODUCTION: In elderly patients, an established treatment for femoral neck fractures is hip hemiarthroplasty (HHA) using the anterolateral approach (ALA). Early postoperative mobilization is crucial to reduce perioperative complications. The direct anterior approach (DAA) has been reported to facilitate early recovery of ambulation and is increasingly popular in elective hip surgery but rarely used in femoral neck fractures. The aim was to compare the outcome of the DAA and the ALA in patients treated for femoral neck fracture. MATERIALS AND METHODS: All HHAs with complete data sets were reviewed from a tertiary public healthcare institution (2013-2020). Propensity score matching was applied to compensate for possible confounders; outcome parameters were perioperative blood loss, postoperative mobility and pain. Secondary outcomes were duration of surgery, length of stay (LOS), complications, reoperation and mortality rates. RESULTS: There were 237 patients (mean age 85.8 years) available for analysis. The DAA group mobilized earlier during hospitalization (outside patient room: 50.6 vs 38.6%, p = 0.01; walking on crutches/walker: 48.1 vs 36.1%, p < 0.01), had shorter surgeries (DAA vs ALA: 72.5 vs 89.5 min, p < 0.001) and a trend towards fewer complications (32.9% vs 44.9%, p = 0.076). Blood loss (286 vs 287 ml), LOS (10.4 vs 9.5 days), pain (cessation of opioid medication: 2.9 vs 3.3 days post-op), revision (2.5 vs 3.2%) or mortality (30-days: 7.6 vs 5.7%) did not differ between patient groups. CONCLUSIONS: DAA for HHA led to earlier in-hospital mobility, shorter surgeries and a tendency towards fewer complications. No advantage was found regarding perioperative blood loss and pain.

Cementless total hip arthroplasty with anatomic-shaped implants. Does the minimal invasive anterolateral technique influence the stem position or subsidence in contrast to the standard lateral approach?

INTRODUCTION: Using cementless stems in total hip arthroplasty (THA) has revealed variable results. The risk for early aseptic loosening has been associated to certain surgical approaches and implant designs. This study determines misalignment of collared/collarless stems and the rate of subsidence using the anterolateral approach (ALA) compared to implantations via the direct lateral approach (DLA). MATERIALS AND METHODS: One hundred consecutive patients underwent primary unilateral THA using the minimal invasive ALA in the lateral decubitus position and were compared to another cohort of 100 patients, treated trough the DLA. Clinical results were noted preoperatively and after 1 year using the WOMAC score. The radiographic evaluation included the stem alignment and subsidence. RESULTS: Overall, all patients improved in WOMAC from 48.9 points (± 11.4; 21.0-82.0) to 3.1 (± 3.2; 0.0-22.0) (p < 0.001). For DLA and ALA, the stem was placed on average 2.5° in varus to the femoral axis. The mean alignment was about 0.5° more valgus for collarless stems. The mean subsidence in the DLA group was about 0.3 mm higher compared to the ALA group. With collarless implants, the subsidence was about 1.0 mm higher compared to collared implants (p < 0.05), especially in patients with Dorr type B femurs. CONCLUSIONS: Changing from the DLA to the minimal invasive ALA did not significantly affect the implant position. Misalignment and a potential risk for early aseptic loosening could not be seen. The use of a collared cementless stem seems safe and is likely to prevent a relevant subsidence, even more so in Dorr type B femurs. LEVEL OF EVIDENCE: III.

A single-surgeon experience in reconstruction of femoro-acetabular offset and implant positioning in direct anterior approach and anterolateral MIS approach with a curved short stem.

PURPOSE: Minimally invasive surgery using short stems in total hip arthroplasty gained more popularity. The differences in change of hip offset and implant positioning in minimally invasive approaches are not fully known. Therefore, this study was conducted to evaluate the difference in reconstruction of hip offset and implant positioning in direct anterior approach (DAA) and minimally invasive anterolateral approach (AL MIS). METHODS: A single surgeon series of 117 hips (117 patients; mean age 65.54 years ± 11.47; index surgery 2014-2018) were included and allocated into two groups: group A (DAA) with 70 hips and Group B (AL MIS) with 47 patients operated. In both groups the same type of cementless curved short hip stem and press fit cup was used. RESULTS: Both groups showed an equal statistically significant increase of femoral (p < 0.001) and decrease of acetabular offset (p < 0.001). Between both groups no statistically significant difference in offset reconstruction, leg length difference or implant positioning could be found. Leg length increased in both groups significantly and leg length discrepancy showed no difference (group A: - 0.06 mm; group B: 1.11 mm; p < 0.001). A comparable number of cups were positioned outside the target zone regarding cup anteversion. CONCLUSION: The usage of a curved short stem shows an equal reconstruction of femoro-acetabular offset, leg length and implant positioning in both MIS approaches. The results of this study show comparable results to the existing literature regarding change of offset and restoration of leg length. Malposition of the acetabular component regarding anteversion poses a risk.

Obesity in short stem total hip arthroplasty using a minimally invasive supine anterolateral approach-a risk factor for short-term complications?

PURPOSE: Obesity is associated with increased risk for surgical complications in total hip arthroplasty (THA). The impact of obesity on short-term complication in minimally invasive (MIS) anterolateral approach is not well known. Therefore, this study was conducted to evaluate the early complications within the first 90 days after THA using a MIS anterolateral approach with a short-curved stem stratified by Body Mass Index (BMI). PATIENTS AND METHODS: A single centre consecutive series of 1052 hips in 982 patients (index surgery 2014-2019) with a short-curved stem and press fit cup implanted using a MIS anterolateral approach in supine position were screened for inclusion. Inclusion criteria were defined as end-stage primary osteoarthritis of the hip. Eventually, 878 implantations in 808 patients were included and stratified by body mass index (BMI). Peri-operative complications, within the first 90 days after surgery, were retrospectively evaluated. RESULTS: Severely obese patients (BMI ≥ 35 kg/m2) and morbidly obese patients (BMI ≥ 40 kg/m2) demonstrated a significantly increased operation time (p < 0.001) and a higher risk for general surgical complications (p = 0.015) (odds ratio (OR) = 4.365; OR = 4.985), periprosthetic joint infection (PJI) (p = 0.001) (OR = 21.687; OR = 57.653), and revision (OR = 8.793; OR = 20.708). CONCLUSION: The risk for early PJI and overall surgical complications in MIS anterolateral approach is significantly increased in severely and morbidly obese patients. This leads to a significantly higher risk for revision surgery after index surgery within the first 90 days. A BMI above 35 kg/m2 is the clear threshold for increased risk of PJI in MIS anterolateral THA with a short curved stem. As the surgical complications are comparable to other approaches, MIS anterolateral short stem THA is also feasible with increasing BMI.

Surgical Outcomes of Articular Surface Crush Injury of Hawkins â ¢ Talus Neck and Medial Malleolus Fracture.

The present study was performed to evaluate the effects of the medial and anterolateral approach combined with internal fixation by double head compression screws and countersunk K-wires for Hawkins Ⅲ talus neck and medial malleolus fracture. Eleven patients with articular surface crush injury resulting in Hawkins Ⅲ talus neck fractures accompanied by medial malleolus fractures were reviewed. All patients underwent emergency operations. The fractures were fixed using double head compression screws and countersunk K-wires through combined medial and anterolateral approaches. FAOS, AOFAS ankle-hindfoot scale, and VAS questionnaire scores were recorded. In addition, ROM of the ankle and postoperative complications were assessed. All patients were followed up for a median of 52.45 ±â€…5.15 months. The multiple scales data of FAOS on the affected side were: pain score 89.14 ±â€…7.08; activities of daily living score 89.57 ±â€…8.88; quality-of-life score 89.20 ±â€…7.44; sports score 75.00 ±â€…15.49; and other symptoms score 84.74 ±â€…7.51. The mean overall AOFAS ankle-hindfoot score was 88.36 ±â€…6.39. The VAS score was 0.72 ±â€…0.65. Ankle motion included dorsiflexion (13.18°â€…±â€…9.02°) and plantar flexion (32.27°â€…±â€…12.34°). Subtalar joint motion included eversion (10.91°â€…±â€…7.01°) and inversion (11.36°â€…±â€…7.45°). All scores of the healthy side were higher than those of the affected side (p < .05). In addition to ROM of the ankle and subtalar joint and sports score, various indicators of recovery rate had scores > 80%. One patient developed skin necrosis, which healed after debridement and wound dressing. Late complications included subtalar and/or ankle traumatic arthritis in six patients, four of whom showed no obvious clinical symptoms. In conclusion, the method of emergency surgery and medial and anterolateral approach combined with countersunk K-wires to fix small bone fragments to restore the integrity of the articular surface is acceptable for Hawkins Ⅲ talus neck with medial malleolus fracture.

Low rate of early periprosthetic fractures in cementless short-stem total hip arthroplasty using a minimally invasive anterolateral approach.

PURPOSE: Minimally invasive (MIS) approaches in combination with short stems have gained popularity in recent years in total hip arthroplasty (THA). A decreased risk for periprosthetic femoral fractures (PFFs) is reported for cementless short-stem THA, but in contrast to other approaches, the risk factors for PFFs for short-stem THA using MIS anterolateral approach in supine position are not described in literature. METHODS: A single-center consecutive series of 1052 hips in 982 patients, performed between 2014 and 2019 with a short curved stem and a press fit using an MIS anterolateral approach in supine position, was retrospectively screened for inclusion. Fourteen patients were lost to follow-up. Therefore, 1038 THAs in 968 patients were included. Risk factors for intra- and postoperative PFFs within 90 days were analyzed. We investigated for sex, age, body mass index (BMI), diagnosis, and laterality. RESULTS: In total, 18 PFFs (1.7%) occurred. Intraoperative fracture occurred in ten cases ( 0.9%), with another eight cases (0.8%) occurring postoperatively. Increased American Society of Anesthesiologists (ASA) Score was a significant risk factor for PFF (p = 0.026), whereas sex (p = 0.155), age (p = 0.161), BMI (p = 0.996), and laterality (p = 1.000) were not. Seven PFFs (0.7%) required revision arthroplasty. CONCLUSION: Cementless short-stem THA using the MIS anterolateral approach is a procedure with a low number of PFFs within 90 days from index surgery. Fracture rates are comparable to other MIS approaches, and comparable femoral short stems are used. Age, sex, and BMI were not identified as risk factors of PFF, while risk for PFF increased with ASA Score. LEVEL OF EVIDENCE: Level IV.