The anterolateral ligament (ALL) is considered as an important stabilizer of the knee joint. This ligament prevents anterolateral subluxation of the proximal tibia on the femur when the knee is flexed and internally rotated. Injury of the ALL was not investigated in patients with knee dislocation. The aim of the current research is to study the prevalence and characteristics of ALL injury in dislocated knees. A retrospective review of charts and radiological images was done for patients who underwent multiligamentous knee reconstruction surgery for knee dislocation in our institution from May 2008 to December 2016. Magnetic resonance imaging (MRI) was used to describe the ALL injury. The association of ALL injury with other variables related to the injury and the patient's background features was examined. Forty-eight patients (49 knees) were included. The mean age of the patients was 32.3 ± 10.6 years. High energy trauma was the mechanism of dislocation in 28 (57.1%) knees. Thirty-one knees (63.3%) were classified as knee dislocation (KD) type IV. Forty-five (91.8%) knees had a complete ALL injury and three (6.1%) knees had incomplete ALL injury. Forty (81.6%) knees had a complete ALL injury at the proximal fibres of the ALL, while 23 (46.9%) knees had complete distal ALL injury. None of the 46 (93.9%) knees with lateral collateral ligament (LCL) injury had normal proximal ALL fibres (p = 0.012). Injury to the distal fibres of the ALL, as well as overall ALL injury, were not associated with any other variables (p >0.05). Moreover, all patients with associated tibial plateau fractures (9, 18.4%) had abnormality of the proximal fibres of the ALL (p = 0.033). High grade ALL injury is highly prevalent among dislocated knees. The outcomes of reconstructing the ALL in multiligamentous knee reconstruction surgery should be investigated in future studies

The anterolateral MIS-THA approach can be divided into the Modified Watson-Jones approach (MWJ) performed in the lateral position and the Anterolateral Supine method (ALS) performed in the supine position. Femoral preparation is flexible in stem selection in the MWJ method. On the other hand, the ALS method is more stable for placement on the acetabular implant. Now we introduce novel anterolateral MIS approach named AL60, it makes use of the merits of both MWJ and ALS methods. Technique. The patient is fixed at 30 degrees on the dorsal side from lateral position. That is 60 degrees on the half side from the horizontal plane, and the platform of the operating table is removed just as in the MWJ method. During surgery, the pelvis is fixed by the posterior support, and the stability of the pelvis is very good. Also, if the inclination is accurate at 30 degrees, by holding the holder parallel to the operating table when inserting the cup, the cup is theoretically inserted at Anatomical anteversion 30 degrees. The intraoperative field of view is also visible to the assistant due to the semi-lateral position. Femoral preparation is easier than the MWJ method because the affected limbs have fallen to the dorsal side already. Discussion. Since March 2017 to the end of August 2018, the AL60 method was used for 207 primary THA. There were no dislocations or fractures and any other complications. Full weight bearing was possible from the next day. The AL60 method has stability of the ALS method for acetabular preparation and the operability of the MWJ method for femoral preparation. Therefore, it can be said that new AL60 approach method makes use of the merits of both MWJ and ALS methods

Objectives. The aim of this study was to investigate the biomechanical effect of the anterolateral ligament (ALL), anterior cruciate ligament (ACL), or both ALL and ACL on kinematics under dynamic loading conditions using dynamic simulation subject-specific knee models. Methods. Five subject-specific musculoskeletal models were validated with computationally predicted muscle activation, electromyography data, and previous experimental data to analyze effects of the ALL and ACL on knee kinematics under gait and squat loading conditions. Results. Anterior translation (AT) significantly increased with deficiency of the ACL, ALL, or both structures under gait cycle loading. Internal rotation (IR) significantly increased with deficiency of both the ACL and ALL under gait and squat loading conditions. However, the deficiency of ALL was not significant in the increase of AT, but it was significant in the increase of IR under the squat loading condition. Conclusion. The results of this study confirm that the ALL is an important lateral knee structure for knee joint stability. The ALL is a secondary stabilizer relative to the ACL under simulated gait and squat loading conditions. Cite this article: Bone Joint Res 2019;8:509–517

Aims. The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty. Patients and Methods. A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months. Results. A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups. Conclusion. The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome. Cite this article: Bone Joint J 2019;101-B:793–799

Injection or aspiration of the ankle may be performed through either an anteromedial or an anterolateral approach for diagnostic or therapeutic reasons. We evaluated the success of an intra-articular puncture in relation to its site in 76 ankles from 38 cadavers. Two orthopaedic surgical trainees each injected methylene blue dye into 18 of 38 ankles through an anterolateral approach and into 20 of 38 through an anteromedial. An arthrotomy was then performed to confirm the placement of the dye within the joint. Of the anteromedial injections 31 of 40 (77.5%, 95% confidence interval (CI) 64.6 to 90.4) were successful as were 31 of 36 (86.1%, 95% CI 74.8 to 97.4) anterolateral injections. In total 62 of 76 (81.6%, 95% CI 72.9 to 90.3) of the injections were intra-articular with a trend towards greater accuracy with the anterolateral approach, but this difference was not statistically significant (p = 0.25). In the case of trainee A, 16 of 20 anteromedial injections and 14 of 18 anterolateral punctures were intra-articular. Trainee B made successful intra-articular punctures in 15 of 20 anteromedial and 17 of 18 anterolateral approaches. There was no significant difference between them (p = 0.5 and p = 0.16 for the anteromedial and anterolateral approaches, respectively). These results were similar to those of other reported studies. Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Placement of the needle may be aided by the use of ultrasonographic scanning or fluoroscopy which may be required in certain instances

The aim of the study is to investigate the biomechanical effects on the pelvis of the anterolateral and posterolateral approaches at the time of hip arthroplasty. In particular the study investigates the change in stress distribution, and the change in muscle recruitment pattern following surgery. The study uses an advanced finite element model of the pelvis, in which the role of muscles and ligaments in determining the stress distribution in the pelvis is included. The model is altered for the posterolateral approach by excision of the external rotators. Different levels of gluteal damage for the anterolateral approach are modelled by excising in turn the anterior third, half, and two-thirds of the gluteus medius and minimus. Although attempt is generally made to repair gluteal damage at the time of surgery, it is clear the muscle volume will be compromised immediately after surgery. In support of previous clinical studies indicating an increased risk of limp, and pelvic tilt following the anterolateral approach, significant differences were found in the muscle recruitment pattern following the anterolateral, compared to the posterolateral approach. During single leg stance and walking force transfer to the iliacus and pectineus was observed. Required levels of muscle force, to maintain coronal balance, following the anterolateral approach were found to be close to maximum sustainable levels. In addition significant alteration to the pelvic stress distribution was found following the anterolateral approach. The effects of increasing gluteal damage for the anterolateral approach were progressive, and became more pronounced when more than fifty percent of the gluteus medius and minimus were damaged. Increases in stresses around the acetabulum were observed for the posterolateral, compared to the anterolateral approach. Thus, based on a biomechanical evaluation, the anterolateral approach presents increased risk of limp, and pelvic tilt, in comparison to the posterolateral approach

The anterolateral ligament (ALL) has been recently recognized as a distinct stabilizer for internal rotation in the ACL-deficient knee and it has been hypothesized that ALL reconstruction may play an important role in improving anterolateral instability following ACL reconstruction. Both the gracilis tendon (GT) and a portion of the iliotibial band (ITB) have been suggested as graft materials for ALL reconstruction, however, there is an ongoing debate concerning whether GT or ITB are appropriate grafting materials. Furthermore, there is limited knowledge in how the mechanical properties of these potential grafts compare to the native ALL. Consequently, the aim of this study was to characterize the elastic (Young's modulus and failure load) and viscoelastic (dynamic and static creep) mechanical properties of the ALL and compare these results with the characteristics of the grafting materials (GT and ITB), in order to provide guidance to clinicians with respect to graft material choice. Fourteen fresh-frozen cadaveric knees (85.2±12.2 yr) were obtained. The ALL, ITB, and the distal (GTD) and proximal gracilis tendons (GTP) (bisected at mid portion) were harvested from each donor and tested with a dynamic material testing frame. Prior to testing, the cross-sectional area of each tissue was measured using a casting method and the force required to achieve a min-max stress (1.2–12 MPa) for the testing protocol was calculated (preconditioning (20 cycles, 3–6 MPa), sinusoidal cycle (200 cycles, 1.2–12 MPa), dwell at constant load (100 s, 12 MPa), and load to failure (3%/s)). Kruskall-Wallis tests were used to compare all tissue groups (p<0.05). The Young's modulus of both ALL (181.3±63.9 MPa) and ITB (357.6±94.4 MPa) are significantly lower than GTD (835.4±146.5 MPa) and GTP (725.6±227.1 MPa). In contrast, the failure load of ALL (124.5±40.9 N) was comparable with GTD (452.7±119.3 N) and GTP (433±133.7 N), however, significantly lower than ITB (909.6±194.7 N). Dynamic creep of the ALL (0.5±0.3 mm) and ITB (0.7±0.2 mm) were similar (p>0.05) whereas the GTD (0.26±0.06 mm) and GTP (0.28±0.1 mm) were significantly lower. Static creep progression of the ALL (1.09±0.4 %) was highest across all tissues, while GTD (0.24±0.05 %) and GTP (0.25±0.0.04 %) were lowest and comparable with ITB (0.3±0.07 %) creep progression. Since grafts from the ITB, GTD and GTP were comparable to the ALL only for certain mechanical properties, there was no clear preference for using one over another for ALL reconstruction. Therefore, further studies should be performed in order to evaluate which parameters play a vital role to determine the optimum grafting choice

There have been differing descriptions of the anterolateral structures of the knee, and not all have been named or described clearly. The aim of this study was to provide a clear anatomical interpretation of these structures. We dissected 40 fresh-frozen cadaveric knees to view the relevant anatomy and identified a consistent structure in 33 knees (83%); we termed this the anterolateral ligament of the knee. This structure passes antero-distally from an attachment proximal and posterior to the lateral femoral epicondyle to the margin of the lateral tibial plateau, approximately midway between Gerdy’s tubercle and the head of the fibula. The ligament is superficial to the lateral (fibular) collateral ligament proximally, from which it is distinct, and separate from the capsule of the knee. In the eight knees in which it was measured, we observed that the ligament was isometric from 0° to 60° of flexion of the knee, then slackened when the knee flexed further to 90° and was lengthened by imposing tibial internal rotation. . Cite this article: Bone Joint J 2014;96-B:325–31

Background. The anatomy of the human body has been studied for centuries. Despite this, recent articles have announced the presence of a new knee ligament- the anterolateral ligament. It has been the subject of much discussion and media commentary. Previous anatomical studies indicate its presence, and describe its location, origin, course and insertion. Magnetic resonance imaging (MRI) is the best and most commonly used investigation to assess the ligamentous structure of the knee. To date, most MRI knee reports make no mention of the anterolateral ligament. The aim of this study was to assess for the presence of the anterolateral ligament using MRI, and to describe the structure if visualised. Methods. All right knee MRIs performed on a Siemens Magnetom Espree 1.5 Tesla scanner in Merlin Park Hospital over a 4 year period were retrospectively analysed. Patients born before 1970, or with reported abnormalities were excluded. The normal MRIs were then analysed by a consultant radiologist specialising in musculoskeletal imaging. Measurements on origin, insertion, course and length were noted. Results. 942 right knee MRIs were performed in the time period. 62 were classed as normal, and within the specified age range. 10 were randomly sampled. Of these the ligament was visible on all 10 MRIs, best viewed in the coronal plane. The average length (visible in 8/10) was 28.88mm +/− 5.14mm. The origin (visible in all 10) was 2.25mm +/− 0.39mm. The insertion (visible in 9/10) was 1.93mm +/− 0.424. The mid thickness was 1.87mm +/− 0.2mm. Conclusions. This study indicates that the ALL is a discrete, visible structure on MRI. This furthers the evidence of the presence of the ALL and also provides information that may be beneficial in future studies, and assessment of knee injuries. Level of evidence. 4

Objectives: Total hip arthroplasty by minimal invasive anterolateral exposure is a technique which causes minimal damage on skin, muscles and bone and lead to early recovery. Current study compared the clinical and radiological results of total hip arthroplaties performed with two different exposure- minimal invasive anterolateral (MIA) and standard anterolateral exposure (SA). Methods: Several parameters of total hip arthroplasty patients managed with two different exposures between 2005 and 2008 were evaluated retrospectively from medical records. First group was consisted of total hip arthroplasty patients managed with SA exposure. 26 hip of 25 patients were operated in this cohort. Mean age, follow up and body mass index was 57±12.45 year, 25.23±8.71 months and 32.52±5.77 respectively. Second group was consisted of total hip arthroplasty patients managed with MIA exposure.15 patients were operated in this cohort. Mean age, follow up and body mass index was 68.93±5.51year, 26.07±7.21 months and 28.69±2.72 respectively. Intraoperative, postoperative, total blood loss, operation time, blood transfusions, length of hospital stay were evaluated. Preoperative; postoperative 1,6,12,24 th hours VAS scores and Harris Hip Score (HHS) in preoperative; postoperative 1,6,12 th months and last controls were evaluated. Femoral component position (varus or valgus), inclination of acetabular component and signs of loosening were evaluated from the last follow up radiographies. Results: Intraoperative, postoperative, total blood loss, blood transfusions, length of hospital stay were significantly reduced in MIA group as compared to SA group (p< 0.05). Average operation times were not different (p=0.259). Improving in VAS scores and HHS was significantly better in MIA group (p< 0.001). Postoperative SF-36 scores were significantly higher in both groups as compared to preoperative scores (p< 0.05). No sign of looseing, osteolysis, superficial or deep wound infection were detected in both groups. Conclusion: Total hip arthroplasty by MIA exposure reduces length of hospital stay, leads to better pain control and rehabilitation in early period, causes less blood loss and leads to significant improvement in SF 36 scores. We suggest that after completion of learning curve, total hip arthroplasty by MIA exposure can be performed more effectively and with less complication

Injury to the anterolateral ligament (ALL) has been reported to contribute to high-grade anterolateral laxity following anterior cruciate ligament (ACL) injury. Failure to address ALL injury has been suggested as a cause of persistent rotational laxity following ACL reconstruction. However, lateral meniscus posterior root (LMPR) tears have also has been shown to cause increased internal rotation and anterior translation of the knee. Due to the anatomic relationship of the ALL and the lateral meniscus, we hypothesise that the ALL and lateral meniscus work synergistically, and that a tear to the LMPR will have the same effect on anterolateral laxity as an ALL tear in the ACL deficient knee. Sixteen fresh frozen cadaveric knee specimens were potted into a hip simulator(femur) and a six degree-of-freedom load cell (tibia). Two rigid optical trackers were inserted into the proximal femur and distal tibia, allowing for the motion of the tibia with respect to the femur to be tracked during biomechanical tests. A series of points on the femur and tibia were digitised to create bone coordinate systems that were used to calculate the kinematic variables. Biomechanical testing involved applying a 5Nm internal rotation moment to the tibia while the knee was in full extension and tested sequentially in the following three conditions: i) ACLintact; ii) Partial ACL injury (ACLam) – anteromedial bundle sectioned; iii) Full ACL injury (ACLfull). The specimens were then randomised to either have the ALL sectioned first (ALLsec) followed by the LMPRsec or vice versa. Internal rotation and anterior translation of the tibia with respect to the femur were calculated. A mixed two-way (serial sectioning by ALL section order) repeated measures ANOVA (alpha = 0.05). Compared to the ACLintact condition, internal rotation was found to be 1.78° (p=0.06), 3.74° (p=0.001), and 3.84° (p=0.001) greater following ACLfull, LMPRsec and ALLsec respectively. LMPRsec and the ALLsec resulted in approximately 20 of additional internal rotation (p=0.004 and p=0.01, respectively) compared with the ACL deficient knee (ACLfull). No difference was observed between the ALL and LMPR sectioned states, or whether the ALL was sectioned before or after the LMPR (p=0.160). A trend of increasing anterior translation was observed when the 5Nm internal rotation moment was applied up until the ACL was fully sectioned; however, these differences were not significant (p=0.070). The ALL and LMPR seem to have a synergistic relationship in aiding the ACL in controlling anterolateral rotational laxity. High-grade anterolateral laxity following ACL injury may be attributed to injuries of the ALL and/or the LMPR. We suggest that the lateral meniscus should be thought of as part of the anterolateral capsulomeniscal complex (i.e., LM, ITB, and ALL) that acts as a stabiliser of anterolateral rotation in conjunction with the ACL

Introduction: The anterior and anterolateral approach to the hip traditionally are well described exposures in primary hip arthroplasty with fewer dislocations than the posterior approach. A very debilitating complication associated with the anterolateral approach however is the persistent limp and positive Trendelenburg sign. We discuss our results with respect to abductor function and morphological integrity seen on MRI when using an approach in which we preserve the majority of gluteus medius. Methods: We carried out a prospective study of thirty-nine consecutive total hip replacements performed through a gluteus medius sparing anterolateral approach. The same hip surgeon performed all these between April and October 2004. Gait analysis and Trendelenburg tests were evaluated during clinical follow-up at six weeks and three months. Coronal STIR and T1 weighted MRI sequences of the abductors were performed between four and six weeks and the findings were agreed by the consensus of two radiologists. Results: At three-month follow-up all thirty-nine patients tested Trendelenburg negative. Post-operative radiographs showed satisfactory femoral and acetabular component position. MRI findings showed the gluteus medius tendon to be intact with no shortening on T1. Artefacts were found to be less marked in the higher field strength magnet but more apparent in the STIR weighted sequences. Discussion: We have tried to incorporate the advantages of reduced dislocation rate of the anterolateral approach, whilst avoiding violation of the abductors. The clinical result and radiographic findings we have presented suggest that the described exposure is an effective and safe method of approaching the hip, with minimal disruption of the abductor mechanism. In addition to maintaining the reduced dislocation rate associated with the standard anterolateral approach. Intact abductor function allows for rapid rehabilitation

Background. Return to sports after anterior cruciate ligament reconstruction (ACLR) is multifactorial and rotational stability is one of the main concerns. Anterolateral ligament reconstruction (ALLR) has been recommended to enhance rotational stability. Purpose. To assess the effect of ALLR on return to sports. Study Design. Retrospective comparative cohort study;. Level of evidence: III. Methods. A total of 68 patients who underwent ACLR after acute ACL injury between 2015 and 2018 with a follow-up of at least 24 months were enrolled in the study. Patients with isolated ACLR (group ALL(-), n=41) were compared to patients with ACLR+ALLR (group ALL(+), n=27) in regard to subjective knee assessment via Tegner activity scale, Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale, Knee Documentation Committee (IKDC) form and Lysholm score. All tests were performed before the surgery, at 6 months and 24 months postoperatively. Results. Mean follow-up was 29.7±2.9 months for group ALL(-) and 31.6±3.0 for ALL(+) (p=0.587). Tegner, ACL-RSI and IKDC scores at last follow-up were significantly better in ALL(+) compared to ALL(-). There were no significant differences in isokinetic extensor strength and single-leg hop test results between the groups. 40 (97.6%) patients in ALL(-) and 27 (100%) in ALL(+) had a grade 2 or 3 pivot shift (p=0.812) preoperatively. Postoperatively, 28 (68.3%) patients in ALL(-) and 25 (92.6%) patients in ALL(+) had a negative pivot shift (p<0.001). 2 (5.9%) patients in ALL(-) and 1 (3.7%) patient in ALL(+) needed ACLR revision due to traumatic re-injury (p=0.165). There was no significant difference in the rate of return to any sports activity (87.8% in ALL(-) vs 88.9% in ALL(+); p=0.532), but ALL(+) showed a higher rate of return to the same level of sports activity (55.6%) than group ALL(-) (31.7%) (p=0.012). Conclusion. ACLR combined with ALLR provided a significantly higher rate of return to the same level sports activity than ACLR alone, probably due to enhanced rotational stability

Purpose. Minimally invasive anterolateral approach (ALA) for total hip arthroplasty (THA) has gained popularity in recent years as better postoperative functional recovery and lower risk of postoperative dislocation are claimed. However, difficulties for femur exposure and intraoperative complications during femoral canal preparation and component placement have been reported. This study analyzes the anatomical factors likely to be related with intraoperative complications and the difficulties of access noted by the surgeons through a modified minimally invasive ALA. The aim is to define the profile for patient at risk of intraoperative complications during minimally invasive ALA. Methods. We retrospectively included 310 consecutive patients (100 males, 210 females) who had primary unilateral THA using the same technique in all cases. The approach was performed between the tensor fascia lata and the gluteus medius and minimus, without incising or detaching muscles and tendons. Posterior translation was combined to external rotation for proximal femur exposure (Fig. 1). All patients were reviewed clinically and radiologically. For the radiological evaluation, all patients underwent pre- and postoperative standing and sitting full-body EOS acquisitions. Pelvic [Sacral slope, Pelvic incidence (PI), Anterior pelvic plane angle] and femoral parameters were measured preoperatively. We assessed all intraoperative and postoperative complications for femoral preparation and implantation. Intraoperative complications included the femoral fractures and difficulties for femoral exposure (limitations for exposure and lateralization of the proximal femur). The patients were divided into two groups: patients with or without intraoperative complications. Results. Ten patients (3.2%) had intraoperative femoral fractures (greater trochanter: 2 cases, calcar: 8 cases). Five fractures required additional wiring. Difficult access to proximal femur was reported in the operative records for 10 other patients (3.2%). There was no difference in diagnosis, age, sex, BMI between the patients with or without intraoperative complications. No significant group differences were found for surgical time, and blood loss. Patients with intraoperative complication, presented a significantly lower pelvic incidence than patients without intraoperative complications (mean PI: 39.4° vs 56.9°, p<0.001). The relative risk of intraoperative complications in patients with low PI (PI<45°) was more than thirteen times (relative risk; 13.3, 95% CI= 8.2 to 21.5. p<0.001) the risk for patients with normal and high PI (PI>45°). Conclusions. Anterolateral approach for THA implantation in lateral decubitus is reported to have anatomical and functional advantages. Nevertheless, the exposure of the femur remains a limitation. This study highlights a significant increased risk in case of low PI less than 45°. This specific anatomical pattern reduces the local working space as the possibility for posterior translation and elevation of the proximal femur is less on a narrow pelvis. This limitation is due to the length and the orientation of the hip abductor and short external rotator muscles related to the relative positions of iliac wing and greater trochanter (Fig. 2). This study points out the importance of pelvic incidence for the detection of anatomically less favourable patients for THA implantation using ALA. For any figures or tables, please contact the authors directly

The anterolateral surgical exposure to the distal tibia for pilon fractures has become more popular. One of the potential benefits over the commonly used anteromedial approach is a reduction in wound complications due to the improved soft tissue coverage of the anterolateral tibia. Minimal data exists regarding the rate of complications with the anterolateral approach. The purpose of this study was to evaluate wound complications in the early postoperative period associated with the use of the anterolateral approach for pilon fractures. Methods: A retrospective review was conducted to identify all operatively treated pilon fractures at our university level 1 trauma center from September 2005 through July 2007. Sixty-eight pilon fractures were identified. All patients were treated with a staged protocol utilizing immediate external fixation followed by delayed open reduction and internal fixation based upon the condition of the soft tissue envelope. Patients who had an anterolateral surgical approach were identified and their medical records were reviewed for the first six weeks postoperatively to determine the rate of wound complications. The endpoint of six weeks was chosen to identify complications related to the surgical exposure alone. Results: Thirty-six of the sixty-eight patients with pilon fractures had an anterolateral surgical exposure. One additional patient had an anterolateral incision performed for revision of a previously treated pilon fracture. 97% of these fractures were AO/OTA 43-C (three C1, nine C2, and twenty-three C3). The median time delay to definitive fixation was 19 days (10–38 days). Sixteen (44.4%) of the fractures were open, ten of which were Gustilo type III (five IIIA, four IIIB, and one IIIC). Eight of the thirty-seven patients had wound complications related to the anterolateral incision within the first six weeks of definitive fixation. Six patients (16%) had minor complications which were successfully treated with dressing changes and oral antibiotics, and two (5%) had major complications, with evidence of deep wound infection that required formal irrigation and debridement. Conclusion: In a case series with a high rate of complex open pilon fractures, open reduction and internal fixation utilizing an anterolateral approach provided good exposure of the distal tibia with a low incidence of early wound complications. Significance: Pilon fractures, especially high energy complex open ones, have a high risk of wound complications. Avoiding complications is the key in managing high energy pilon fractures. This case series provides evidence that the anterolateral approach has a low rate of wound complications in the most complex pilon fractures

We treated 52 patients with impingement of the anterolateral soft tissues of the ankle by arthroscopic debridement. All had a history of single or multiple inversion injuries, without instability. One half had negative stress radiographs (stable group), while the others were positive (unstable group). Their mean age was 31 years and there were 35 men and 17 women. The results were assessed at a mean follow-up of 30 months. Three patients (6%) had a fair result, while 49 (94%) had an excellent or good outcome. No difference was found in the final results between the two groups (p > 0.05). We conclude that anterolateral impingement of the ankle should be considered in a patient with chronic anterolateral pain after an injury, regardless of the stability of the ankle

In 12 patients, we measured the oxygen concentration in the femoral head-neck junction during hip resurfacing through the anterolateral approach. This was compared with previous measurements made for the posterior approach. For the anterolateral approach, the oxygen concentration was found to be highly dependent upon the position of the leg, which was adjusted during surgery to provide exposure to the acetabulum and femoral head. Gross external rotation of the hip gave a significant decrease in oxygenation of the femoral head. Straightening the limb led to recovery in oxygen concentration, indicating that the blood supply was maintained. The oxygen concentration at the end of the procedure was not significantly different from that at the start. The anterolateral approach appears to produce less disruption to the blood flow in the femoral head-neck junction than the posterior approach for patients undergoing hip resurfacing. This may be reflected subsequently in a lower incidence of fracture of the femoral neck and avascular necrosis

Fifty patients who underwent a MacIntosh repair for anterolateral instability of the knee have been reviewed after a mean follow-up of two and a quarter years. The repair abolished a positive anterolateral jerk test in 42 out of 50 knees and at the time of review 37 patients (74 per cent) were involved in some form of active sport, having regained functional and clinical stability. The MacIntosh repair is described in detail and the importance of excluding meniscal lesions as the main cause of instability is emphasised

Aims

The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years.

Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. Methods. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery. Results. The mean age was 29.8 years (Range 18.2–58 yrs). There were 44 females and 34 males in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required arthroscopic debridement was 48.7 %(38 ankles). A further 10 ankles revealed non-specific synovitis and scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral lesions is 91% and 100%. Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously published literature. However, soft tissue impingement lesions have a much higher incidence and require debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament reconstruction of the ankle is quintessential in the management of chronic anterolateral instability

Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. Methods. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery. Results. The mean age was 29.8 years (Range 18.2 – 58 yrs). There were 44 females and 34 males in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required arthroscopic debridement was 48.7% (38 ankles). A further 10 ankles revealed non-specific synovitis and scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral lesions is 91% and 100%. Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously published literature. However, soft tissue impingement lesions have a much higher incidence and require debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament reconstruction of the ankle is quintessential in the management of chronic anterolateral instability

Introduction. Most Japanese patients who receive total hip arthroplasty (THA) are osteoarthritic and 70% have development dysplasia of the hip. Their stature is shorter than average and their sizes (acetabular cup and femoral stem) are smaller. The Taperloc Microplasty (BIOMET) is a short femoral stem. It was launched on July 2012 in Japan (extended on January 2013). It is essentially a shortened version of the Taperloc stem (35mm shorter than the standard stem). Objectives. We aimed to evaluate the outcomes of minimally invasive anterolateral THA using a short stem. Methods. We retrospectively reviewed all 56 patients who underwent THA at our hospitals between July 2013 and April 2015. Of these 28 (50%) were performed with short stems. The surgical approach was antero-lateral in the lateral position. The patients (4 men and 24 women) had a mean age at surgery of 66.5 years (range, 46–85 years). The original diseases were osteoarthritis (25 patients) and osteonecrosis (3 patients). We investigated the system type, size (cup, femoral head, and stem), radiological findings and complications (fracture, infection, deep vein thrombosis, and dislocation). Results. There were no severe complications, such as, infection, deep vein thrombosis, or dislocation. One patient had a femur fracture during operation and was switched to a standard stem. The mean surgery duration was 102 minutes (range, 80–142 minutes) and the mean amount of bleeding during surgery was 254 g (range, 95–720 g). Mean cup size was 51.0 mm (range, 48–60 mm) and stem size is 6 (range, 4–13). Radiological findings showed 2 patients had stem subsidence (within 5mm). One of them had severe osteoporosis and the other patient had leg length discrepancy. Conclusions. Minimally invasive anterolateral THA using a short femoral stem has good clinical and radiological results in Japanese patients. Long-term results should be further observed prospectively

Introduction. In the setting of periprosthetic joint infection, the complete removal of implants and cement can be challenging with well-fixed, cemented implants about the knee. This can get especially complex in the setting of long cemented femoral stems. Osteotomies are well described in the proximal femur and tibia for removal of implants and cement. There is little information available on distal femoral osteotomies to facilitate knee implant and retained cement removal. Methods. We describe a novel anterolateral oblique distal femoral osteotomy for the removal of well-fixed, cemented components during resection knee arthroplasty that preserves vascularity to the osteotomized segment. Cadaveric anatomic vascular injection studies were performed to document vascularity of the osteotomized segment. Clinical examples, and results will be presented. Results. Anatomic vascular studies documented preserved vascularity to the osteotomized segment. In two patients intramedullary infected implant and cement was completely removed. At reimplantation and final followup the osteotomy was radiographically healed, implants well fixed, and no recurrent infections were noted. Conclusions. This osteotomy appears to be useful when removing well fixed, cemented femoral components during periprosthetic infection. Vascularity and union was preserved and obtained in all patients. For figures, tables, or references, please contact authors directly

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0). The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed. The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care. The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described

Introduction. Since2007, we have used CT-based fluoroscopy-matching navigation system (Vector Vision Hip Ver.3.5.2, BrainLAB, Germany) in Total hip arthroplasty. This system completes the registration procedure semi-automatically by matching the contours of fluoroscopic images and touching 3 adequate points to the contours of 3D bone model created in the computer. Registration procedure using fluoroscopic figures has finished before making surgical incision. It needs no elongation time during the operation. The accuracy of navigation system depends on the techniques of registration used for the navigation and secure fixation of the dynamic reference markers. These could be affected by the different type of approaches. The objective of this study was to evaluate the accuracy of CT-based fluoroscopy-matching navigation system in THA and compare the cup position by anterolateral and posteolateral approaches. Material and method. We analysed the acetabular cup in consecutive 132 hips with both intra-operative and post-operative alignment data (based on navigation system and CT evaluation), including 65 cases with anterolateral approach(Modified Watson Jones) (Group AL) and 67 cases with posterolateral approach(Group PL). We aimed the cup angle for THA as following, the inclination: 40 degrees, the anteversion: 20 degrees. Anteversion on the navigation system must be adjusted by the pelvic tilt. Results. The average of the operative time were 84.8 ± 13.5 in group AL and 89.3 ± 15.1 minutes in group PL. There was one dislocation in group AL. There was no other obvious complication (nerve palsy, VTE and Infection) in these two groups. The all cup alignments were within 8 degrees from the preoperative orientation. The differences between the intra- and post-operative measurement of cup inclination were 1.9 ± 1.6 degrees in group AL and 2.1 ± 1.1 degrees in group PL(N.S.). The differences between the intra- and post-operative measurement of cup anteversion were 2.3 ± 1.4 degrees in group AL and 2.2 ± 1.3 degrees in group PL (N.S.). Discussion. CT-based navigation THA is very useful for severe deformity of hip osteoarthritis. We had used CT-based navigation system(landmark matching) since 2003. It needs some technical skills to improve the accuracy of landmark matching. The registration with CT-based fluoroscopy-matching navigation system is much easier and more simple than with landmark matching navigation system. And we found this system provided high accuracy even in severe deformity cases. There was no significant difference with anterolateral and posterolateral approaches by using CT-based fluoroscopy-matching navigation system

Background: In order to achieve a minimized need for tissue dissection resulting in a faster rehabilitation, minimally invasive surgery (MIS) in Total Hip Arthroplasty (THA) was developed. In this small incision technique the skin and musle dissection has been reduced with respect to the classical approach. Literature shows ambiguous results comparing the posterolateral minimally incisive with the classical approach. As the anterolateral approach is also a routine procedure, and to test how minimally invasive MIS is, we hypothesized that patients treated with a THA using a posterolateral or anterolateral MIS would experience improved clinical results compared with a standard incision after six weeks and no clinical differences after one year. This was tested in a double-blind randomized controlled trial with the Harris Hip Score (HHS) as a primary endpoint. Methods: One hundred and twenty consecutive primary uncemented THAs were randomized into one of four groups of 30 patients each. Either standard posterolateral or anterolateral approaches (PL- or AL-CLASS), or minimal invasive posterolateral or anterolateral approaches (PL- or AL-MIS) were performed. CLASS incisions were 18 cm. To avoid postoperative bias, MIS incisions were extended at skin level to 18 cm at the end of the procedure. The HHS as well as patient-centered questionnaires (SF-36, WOMAC and OHS) was obtained preoperatively, at six weeks and one year after the index operation. Preoperative data, blood loss, hemoglobin, muscle damage parameters and radiological parameters were analyzed. In order to detect a minimal clinically important difference of five points or more between the MIS or CLASS groups with respect to the Harris Hip Score at the 0.05 alpha level with 80% power, 120 patients were enrolled in the study. Results: Mean incision length of the THAs performed by MIS was 7.8 (SD = 1.6). In the patients of the MIS group a significant increased mean HHS was observed compared with the CLASS (p = 0.03) after six weeks and one year. This difference was caused by the favorable results of the PL-MIS (p = 0.009). Of the three patient-centered questionnaires, the SF-36 results were also favourable in the PL-MIS group after six weeks (p = 0.04). In the MIS group operation time was longer (p < 0.001) and a learning curve was observed based on operation time and complication rate. Peri-operative complications rates were not significantly different between the groups. Blood loss, hemoglobin, muscle damage parameters and radiological parameters also showed no difference. Conclusions: This double-blind, randomized study reveals an improved clinical outcome of the PL-MIS compared with the AL-MIS, PL-CLASS and AL-CLASS after six weeks and one year follow-up with the Harris Hip Score as primary endpoint

Purpose: The purpose of our retrospective analysis was to describe results of arthroscopic treatment of painful ankle instability without clinical or radiological laxity. Material and methods: Eighteen patients, mean age 27 years (seven men and nine women) were operated on by the same surgeon between 1999 and 2000. Sixteen patients (90%) were reviewed by an independent investigator at 20±4 months. Fifteen patients were athletes, ten at the competition level, and five had amateur sports activities. The accident caused forced inversion in 15/16 cases, during sports activities in 85.5% of the cases. Mean age at injury was 17±6 years. Mean time between the accident and arthroscopy was eight years. All patients had pain in the anterolateral region associated with effusion in 50% and apprehension or instability for daily life activities. Standard x-rays were normal in fourteen patients (87.5%). Comparative stress images did not demonstrate pathological laxity. Complementary imaging (MRI, CT scan, arthroscan, ultrasonography) was obtained in six patients with 50% negative results. Arthroscopy revealed anterior tissue interposition (antero lateral in thirteen patients (81%) and anteromedial and anterolateral in three) which was removed with the shaver. Joint cartilage was intact in fifteen patients (81.25%). Results: At last follow-up, functional outcome was good in all patients who had all resumed their sports activities. Subjectively, six patients felt they had normal function, seven nearly normal function and three abnormal function (81% satisfied or very satisfied). Six patients were symptom free even during intense physical activity. Eight patients reported some difficulties for strenuous exercise and two for moderate exercise. Joint motion was normal in ten patients and 5° dorsal flexion deficit was observed in six. There were no recurrent sprains. The x-ray was normal and identical to the initial image in 87.5% of the patients. Globally, 87.5% of the patients had good or excellent outcome. Two patients had fair or poor outcome. Discussion: Diagnosis of anterolateral ankle conflict can be established in patients with a compatible history and a typical clinical presentation with normal x-rays. Arthroscopic treatment can remove tissue interposition allowing good functional results and total recovery of sports activities. Complementary MRI or arthroscan have little specificity and poor sensitivity

Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient

Recent National Institute for Health and Care Excellence (NICE) guidance has advised against the continued use of the Thompson implant when performing hip hemiarthroplasty and recommended surgeons consider using the anterolateral surgical approach over a posterior approach. Our objective was to review outcomes from a consecutive series of Thompson hip hemiarthroplasty procedures performed in our unit and to identify any factors predicting the risk of complications. 807 Thompson hip hemiarthroplasty cases performed between April 2008 and November 2013 were reviewed. 721 (89.3%) were cemented and 86 (10.7%) uncemented. 575 (71.3%) were performed in female patients. The anterolateral approach was performed in 753 (93.3%) and the posterior approach with enhanced soft tissue repair in 54 (6.7%). Overall, there were 23 dislocations (2.9%). Dislocation following the posterior approach occurred in 13.0% (7 of 54) in comparison to 2.1% (16 of 753) with the anterolateral approach (odds ratio (OR) 8.5 (95% CI 2.8 to 26.3) p < 0.001). Surgeon grade and patient history of cognitive impairment did not have a significant impact on dislocation rate. Patients were discharged home in 459 cases (56.9%), to a care home or other hospital in 273 cases (33.8%). 51.8% (338 of 653) returned home within 30 days. 75 died during their admission (9.3%). 30-day mortality was 7.1% and 1-year mortality was 16.6%. Intraoperative fracture occurred in 15 cases (1.9%) of which 14 were cemented. Superficial or deep infection occurred in 33 cases (4.1%). We recommend against the continued use of the posterior approach in hip hemiarthroplasty, as enhanced soft tissue repair did not reduce dislocation rates to an acceptable level. Our findings, however, demonstrate satisfactory results for patients treated with the Thompson hip hemiarthroplasty performed through an anterolateral approach. We suggest that the continued use of the Thompson implant in a carefully selected patient cohort is justifiable

Purpose: The purpose of this study was to evaluate the clinical effectiveness and outcomes of the ‘abductor sparing’ MIS Anterolateral approach (MIS Watson Jones/G3) in comparison to the MIS Direct Lateral and MIS Posterolateral approaches in primary total hip arthroplasty. Method: A multicentre, prospective, randomized controlled trial was designed to evaluate for the superiority of the new MIS Anterolateral approach (MIS Watson Jones/ G3). The sample size calculation was performed for alpha .05, power .90, to evaluate for effect size 0.5 in WOMAC using repeated measures analyses with baseline WOMAC as covariate. A total of 156 patients consented to participate in the trial and patients were assigned to MIS Antero-lateral approach or alternate MIS approach (MIS Direct Lateral or MIS Posterolateral). Patients were subjected to standardized anaesthetic and perioperative management protocols and were evaluated at standardized intervals to evaluate endpoints of early recovery (3 months) as well as endpoints of 12 and 24 months respectively. The primary outcome of interest was WOMAC, however secondary outcomes included SF-36, as well as parameters of health resource utilization and complications. Univariate and multivariate analyses were perfomed. Results: Patient groups were found to be similar at baseline with regards to demographics and baseline quality of life outcomes (p> .05). Multivariate and repeated measures analyses demonstrated no superiority of the MIS Anterolateral approach on outcomes of WOMAC and other quality of life measures in comparison to MIS Direct Lateral and MIS Posterolateral approaches (p> .05). Health care resource utlization was also similar with length of stay, blood transfusion requirements and complications (p> .05). Conclusion: Our multicentre, prospective, randomized clinical trial demonstrates that the MIS Anterolateral approach is not superior to alternate MIS surgical approaches when evaluating outcomes of quality of life, complications, and health resource utilization. Surgeons should consider these outcomes, complications, and other relevant advantages and disadvantages of select surgical approaches when deciding on a technique for use in their orthopaedic practice

Our previous reports on the pathological anatomy and operative treatment of intra-articular fractures of the calcaneum failed to take account of the fracture pattern anterior to the posterior facet of the subtalar joint. We have reviewed our experience of 63 operative cases and have studied fractures with axial and coronal CT scans reconstructed onto plastic model bones. A constant anterolateral fragment exists, which is displaced by an extended lateral approach to the fracture. If it is unrecognised and unreduced, union in a displaced position may limit hindfoot eversion and disrupt the calcaneocuboid joint. We describe techniques for reduction and fixation of the fragment

Of a total of 905 patients with fracture or fracture-dislocation of the thoracolumbar spine admitted from 1969 to 1982, a neurological deficit was present in 334 (37%). All unstable injuries were initially treated by reduction and posterior fusion. In 79 of these patients, an anterolateral decompression was undertaken later because of persistent neurological deficit and radiographic demonstration of encroachment on the spinal canal. One patient died of pulmonary embolism; 78 were reviewed after a mean period of four years. Of these 78 patients 18 made a complete neurological recovery while 53 appeared to have benefited from the procedure; 25 remained unchanged. The best results were obtained in burst fractures at thoracolumbar and lumbar levels when a solitary detached fragment of a vertebral body had been displaced into the spinal canal. These results indicate that anterolateral decompression of the spinal canal should be considered, after careful evaluation, for certain injuries of the spine in which there is severe neural involvement

Introduction: Avascular necrosis of the femoral head may play a role in failure of the femoral component in metal on metal hip resurfacing arthroplasty. The purpose of our study was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty in the posterior and anterolateral approaches. Methods: 20 hip resurfacing arthroplasties were performed in 19 patients between September 2005 and March 2006 by two different surgeons; one using the extended posterior approach and the other an anterolateral approach. There were an equal number of procedures for each approach. 1.5 gms of intravenous cefuroxime was administered following caspsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime. The average time taken to prepare the femur and take samples was 8.5 minutes. Results: The concentration of cefuroxime in bone was significantly greater when using the anterolateral approach (mean 15.7mg/kg; CI 12.3 – 19.1) compared to the posterior approach (mean 5.6mg/kg; CI 3.5 – 7.8; p< 0.001). In one patient, who had the operation through a posterior approach, cefuroxime was undetectable. Discussion: The posterior approach is associated with a significant reduction in the blood supply to the femoral head during hip resurfacing arthroplasty. This may be a cause for avascular necrosis and potential failure of the femoral component in this procedure

The purpose of this experimental study was to elucidate the accuracy of neck-cut PSG setting, and femoral component implantation using neck-cut PSG in the THA through the anterolateral-approach relative to the preoperative planning goals, and to determine the usefulness of PSG compared with the procedure without PSG. A total of 32 hips from 16 fresh Caucasian cadaveric samples were used and classified into 4 groups: cementless anatomical stem implantation with wide-base-contact PSG (AWP: 8 hips, Fig.2); (2) cementless anatomical stem implantation with narrow-base-contact PSG (ANP: 8 hips, Fig.2); (3) cementless anatomical stem implantation without PSG (Control: 8 hips); and (4) cementless taper-wedge stem implantation with wide-base-contact PSG (TWP: 8 hips). The absolute error of PSG setting in the sagittal plane of the AWP group was significantly less than that of the ANP (p=0.003).THA with wide-base- contact PSG resulted in better alignment of the femoral component than THA without PSG or with narrow- base-contact PSG. Although the neck-cut PSG did not control the sagittal alignment of taper-wedge stem, the neck-cut PSG was effective to realise the preoperative coronal alignment and medial height for THA via the anterolateral approach regardless of the femoral component type. For figures and tables, please contact authors directly

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°. The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved

Aims: The purpose of this study was to compare the hip abductor strength in patients undergoing total hip replacement via anterolateral (Müller) or posterolateral (Gibson) approach. Methods: Biomechanical studies were performed prospectively on a group of 80 patients who underwent hip arthroplasty via the anterolateral (48 cases) or posterolateral approach (32 cases). There were 61 females and 19 males with an average age of 57 years (range 37 – 78 years). The isometric abductor strength was measured with the kinetic communicator device preoperatively and 6, 12 and 24 weeks postoperatively. Results: Hip abductor strength improved postoperatively in both groups. The posterolateral surgical approach was associated with statistically significant higher abductor strength values. Conclusions: Posterolateral approach significantly increases the isometric abductor strength in relation to the anterolateral approach

The Dall approach is a modified anterolateral approach with osteotomy of the anterior part of the greater trochanter. This approach relatively preserves the soft tissue tension during total hip arthroplasty (THA). We insert the stem and select a ball neck size so as to have a stable hip which will not dislocate easily during the trial reduction. The aim of this study is to evaluate the adequacy of this method, to measure leg length discrepancy and offset discrepancy at postoperative radiographs. We selected patients for inclusion in this study from those who have more than a 120 degree of affected hip flection angle, the opposite hip is almost normal with a low leg length discrepancy (primary OA, osteonecrosis, Crowe 1 secondary OA, femoral neck fracture). All THA were performed with cement fixation using an alignment guide to ensure accurate acetabular positioning. The ball head's diameter used were all 26mm. From September 2011 to October 2013, 22 patients met inclusion criteria among 103 THA. The mean age for 22 subjects was 66.6±12 years. The mean flexion angle of preoperative hip joints was 127.2±6.1 degrees. The cup inclination was 43.8° ± 3.5°. Anteversion was 11.8°±6°. The mean preoperative leg length discrepancy was 5.8mm±6.3mm. The mean postoperative leg length discrepancy was 0.7±3.5mm. The mean postoperative offset discrepancy was 0.7±6.6mm. There were no dislocations in this series of 103 cases. Discussion. Dislocation and leg length discrepancies are major complications following a total hip arthroplasty. A good range of motion of the preoperative hip joint is considered a high risk dislocation factor. The Dall approach with minimal release of soft tissue related to a tension of hip joint offers maximal stability and the ability to accurately restore leg length

Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. In this study we identify structures are risk during this approach. Method. Thirteen unpaired adult lower limbs were used for this study. Thirteen, 16-hole synthes®LCP anterolateral distal tibial plates were percutaneously inserted according to the manufacturer instructions and confirmed by xray. Dissection was performed around the plate to examine the relation of nerves and soft tissue. Results. The neurovascular bundle was under the plate in one case. Over the horizontal limb of the plate, typically the superficial peroneal nerve had a variable course over all four screw holes. The anterior tibial artery coursed over hole number 3 and the Extensor hallucis longistendon was positioned over hole 3 or 4. The Anterior tibialis tendon skirted hole 4 in 12 cases. Over the vertical limb of the plate, the neurovascular bundle coursed over holes, 5 to 7, the superficial peroneal nerve over holes 5 to 7. Discussion. Meticulous attention is required when placing an anterolateral distal tibia plate using a MIPO technique. We recommend a larger initial incision to avoid entanglement of the superficial peroneal nerve under the plate. Over the anterior aspect of the tibia, an open technique with adequate neurovascular structure and tendon protection is necessary due to the variability of structure coursing over the plate. A bridging technique for placement of proximal locking screw should be made through a mini open incision and this is safe to do so proximally over holes 12 to 16. Caution is advised during placement of screws percutaneously from holes 1 to 12 however the neurovascular bundle courses commonly over holes 5 to 7. These landmarks also apply to the use of shorter anterolateral distal tibial plates

We reviewed 64 anterolateral decompressions performed on 63 patients with tuberculosis of the dorsal spine (D. 1. to L. 1. ). The mean age of the patients was 35 years (9 to 73) with no gender preponderance. All patients had severe paraplegia (two cases grade III, 61 cases grade IV). The mean number of vertebral bodies affected was 2.6; the mean pre-treatment kyphosis was 24.8° (7 to 84). An average of 2.9 ribs were removed in the course of 64 procedures. The mean time taken at surgery was 2.45 hours when two ribs were removed and 3.15 hours when three ribs were removed. Twelve patients (19%) showed signs of neurological recovery within seven days, 33 patients (52%) within one month and 12 patients (19%) after two months; but six patients (10%) showed no neurological recovery. Forty patients were followed up for more than two years. In 34 (85%) of these patients there was no significant change in the kyphotic deformity; two patients (5%) showed an increase of more than 20°

Aim. The objective of this study was to evaluate the intermediate term clinical and radiological results of a new short stem hip implant. Methods. In 20 consecutive patients suffering from osteoarthritis with 25 affected hip joints (five cases were bilateral), the clinical and radiological results of 25 hip arthroplasties performed in one hospital between October 2009 and May 2014 through a minimally invasive anterolateral approach using a cementless short stem prosthesis type Aida and a cementless cup type Ecofit with a ceramic on ceramic pairing were evaluated prospectively. The median age of patients at time of surgery was 60 years (range, 42–71 years), 15 male (4 were bilateral) and 5 female patients (one was bilateral) were included in the study. The median clinical follow up was 30 months (range, 2–88 months), and the median radiological follow up was 30 months (range, 2–88 months). Results. Harris Hip Score improved from a median preoperative value of 53 to a median postoperative value of 96 (range, 73–100) at follow up. 22 hips (88%) showed an excellent postoperative Harris Hip Score, 2 hips (8%) a good postoperative Harris Hip Score, and one hip (4%) a fair postoperative Harris Hip Score. Only two patients complained of postoperative thigh pain. Regarding patient satisfaction, 15 patients (60%) were very satisfied, 10 patients (40%) were satisfied. None was unsatisfied. Radiological analysis showed that 19 stems (76%) were with stable bony ingrowth, two cases (8%) showed stable fibrous ingrowth. Four cases need further follow up for proper evaluation of stem fixation.(See Figures 1,2,3). Conclusion. The intermediate term survival of this new short stem is very promising, and achieving the goals of a standard hip arthroplasty. For any figures or tables, please contact the authors directly

Introduction. Migration of the trial femoral head is a rarely occurring complication of total hip arthroplasty (THA) performed using the anterolateral approach (ALA). This migration of the trial femoral head under the rectus femoris is extremely risky because of the anatomical situation. Analyzing the morphological character of a case of migration may help us to avoid this risk. Objective. We analyzed the three-dimensional bone morphology using computed tomography (CT) scan images to investigate the physiological characteristics of five migration cases. Methods. We examined 108 patients (21 men, 87 women, 113 hips) who underwent THA via the ALA. The average patient age was 62.9 (range: 30–87) years and average body mass index was 24.4 (range: 18.0–36.0) kg/m2. The exclusion criteria were dysplastic coxarthroses greater than Crowe type II, previous fractures, previous hip operations, and muscle disease. Three-dimensional models of the pelvis and femur were made using ZedHip software® (Lexi, Tokyo, Japan). The anterior superior iliac spine on the affected side (A) and contralateral side (A’), anterior inferior iliac spine (I), and greater trochanter tip (G) were noted in these models. The distances A–I, I–G, and A–G and the angle formed by AA’ and AI were measured (Figure 1, 2). Each hip was classified by the presence (group M) or absence (group N) of migration during surgery. A Fisher's exact probability test, Student's t-test, and Welch's t-test were used to compare the two groups, and p-values less than 0.05 were considered significant. Results. In 5 of the 113 hips, the trial femoral heads migrated under the rectus femoris and were removed safely. No significant differences were found between the gender, height, weight, or BMI of the groups. The average A–I distance was 32.3±3.0 mm (mean±SD) in group M and 39.4±10.4 mm in group N; I–G was 52.2±8.2 mm in group M and 59.7±10.6 mm in group N; and A–G was 64.3±10.3 mm in group M and 76.3±12.3 mm in group N. The average angle formed by AA’ and AI was 50.5±5.8°. Significant differences between the two groups were found for the distances A–I and A–G. Conclusions. In 4.4% of cases, the trial femoral heads migrated under the rectus femoris, which creates a risk for serious complications because major nerve and blood vessels are located nearby. The tendency for migration was expected to be related to the balance between soft tissues. In this study, we found that migration tends to occur in patients with shorter distances between A and I, and A and G. The trial head should be dislocated more carefully in those patients

Background. Percutaneous vertebroplasty (PVP) is a well established procedure with respect to improved pain and function following vertebral compression fracture. Currently, there is no consensus on the optimal cement distribution within a treated vertebral body. The aim of this study was to determine the influence of two distinct patterns of cement distribution following PVP on patient reported outcome measures up to 1 year post procedure. Methods. A retrospective study was undertaken of 42 patients consecutively undergoing PVP of up to 3 levels by a sole operator. Immediate post-procedural CT scans were analysed with VOXAR MPR software to determine cement distribution in each treated vertebrae as one of two defined patterns -“anterolateral” or “diffuse”. Patients completed an EQ-5D questionnaire pre-procedure and at 1, 2, 6 and 12 months from the procedure. Results. A 97% follow up rate of questionnaire completion was achieved for 30 patients. There were 58 treated levels with PVP performed at all levels between T6 and L5. Twelve patients had an anterolateral fill pattern and 18 patients had a diffuse fill pattern. Statistically significant improvement occurred in in all EQ-5D domains except self care at almost all timepoints in the study group. In the anterolateral group, pain was significantly improved at 1 week, 2months, 6 months and 1 year compared with only at 1 year in the diffuse group. Conclusion. PVP leads to immediate and sustained improvement in quality of life. Lateral cement placement leads to greater pain relief in the short term compared with diffuse cement filling. Conflicts of Interest. None. Source of Funding. None. This abstract has not been previously published in whole or in part; nor has it been presented previously at a national meeting

Purpose of the study: The purpose of this study was to assess traumatic damage to muscles using biological markers. Two approaches were evaluated: a modified Hardinge approach (anterior hemimyotomy) and a reduced anterolateral approach (Rottinger). Material and method: This was a multicentric prospective study conducted in three centres in 2008. The first 50 patients in each centre were included. Total creatinine phosphokinase (CPK) and serum myoglobulin levels were used to evaluate muscle damage. Blood samples were taken ten hours after surgery for myoglobulaeia and at one and two postoperative days for CPK. Student’s t test was used for the statistical analysis. Results: There was no statistically significant difference in serum myoglobulin levels 10 hours postoperatively (p=0.25) or for CPK level at day 1 (p=0.098) and day 2 (p=0.105). Objective clinical recovery (Postel-Merle-d’Aubigné, Harris) and function (WOMAC and SF-12) were better at six weeks with the reduced anterolateral approach. Discussion: These findings show that muscle aggression after mini-incision is to the same order as with the standard approach. The damage is however different: section for the Hardinge type approaches, stretching and contusion for the mini-incisions. Conclusion: Use of biological markers specific for muscle tissue appears to be a simple way of quantifying muscle damage. However, adjunction of an imaging technique (MRI) might provide a more precise assessment of muscle injury

Purpose of the study: Survival of a total hip arthroplasty (THA) mainly depends on the choice of the implant and the quality of the implantation. Use of minimally invasive approaches remains a subject of controversy due to the uncertain implant position and questions concerning increased perioperative complications. The purpose of this work was to assess these two elements in a consecutive series of patients who underwent THA implanted via the minimally invasive anterolateral approach described by Rottinger. Materials and Methods: This was a consecutive series of 130 patients (84 female, 46 male, mean age 69 years, age range 46–91) operated by the same surgeon. Mean follow-up was twelve months (range 6 – 24 months). The clinical parameters studied were: the pre–and post-operative Postel-Merle-d’Aubigné (PMA) score, mean operative time, presence of perioperative surgical complications. Radiographic parameters studied were lucent lines (De Lee and Gruen), homogeneous cementing of the femoral piece, axial position of the femoral implant, angle of acetabular inclination, acetabular anteversion (Hassan), and any leg length discrepancy. Results: Intraoperative complications were: one intraoperative mobilisation of a press-fit cup, one trochanter fracture. Postoperatively, the rate of dislocation was 2.3%. In 3.8% of the patients developed skin lesions or a local haematoma but none with infection. Mean operative time was 107 minutes (range 80–210). Mean postoperative PMA score was 17.4 versus 12.4 preoperatively. Patients were able to walk without limping 3.3 months postoperatively (range 0.5–12 months). Mean cup inclination and anteversion were 46.1° (28–60°) and 12.3° (0–35°) respectively. Leg length discrepancy was +4.8mm on average (operated side). Femoral alignment was ±3° relative to the femoral axis in 83% of hips. Homogeneous cementing of the femoral stem was noted in 84%. There was a learning curve with an 11% complication rate for the first twenty hips versus 4% for the remainder of the hips in this series. Discussion: In our hands, the minimally invasive anterolateral approach described by Rottinger enables proper reproducible THA implantation. The rate of intraoperative complications is low. There is a learning curve which was an estimated twenty cases in our series. This method has become our first-intention option for implantation of THA

As much as there is interest in mini-invasive surgery (MIS) total hip arthroplasty (THA), there is controversy ranging from a more advantageous to a potentially dangerous alternative to classic THA. The purpose of this study is to compare the results of 130 cementless, standard stem navigated primary THA with data collected retrospectively from 2005 to 2010 (64 classic Hardinge approach (HAL) and 66 MIS intermuscular anterolateral approach by the senior surgeon). Data include: operative time, perioperative bleeding, length of surgery, hospital stay, patient's satisfaction and pain perception. The alignment values at six months to a maximum of 60 months provided necessary statistical information for clinical and radiological comparison of the two groups. Significant differences were found between the two groups with MIS being superior with respect to less surgical time (p = 0.029) and achieving quicker rehab goals with shorter hospital stay (p <0.001). Pain perception was less in MIS group with a higher satisfaction score (p <0.001). Although both groups have the potential of nerve injury to tensor fascia muscle, it's only the classic HAL that jeopardises the glutei nerve supply. MIS approach to navigated THA seems to be an acceptable alternative with some advantages to Classic HAL

This single incision, anterolateral intermuscular approach (AL-IM) utilises the interval between gluteus medius and tensor fascia lata. The aims of the study were to compare the quality of life, satisfaction and complications of this approach with two of the most commonly used limited incision transmuscular (TM) approaches, namely the mini-posterior (P-TM) and the mini-direct lateral (L-TM). One hundred and ninety-nine patients receiving MIS THA surgical procedures were evaluated prospectively (63 AL-IM, 68 P-TM and 68 L-TM). The outcome variables were WOMAC function, pain, stiffness, SF-12 (physical & mental), Oxford-12, satisfaction and radiological outcome. Parametric and non-parametric analyses were performed. There were no significant differences between groups in baseline characteristics including age, sex, BMI, co-morbidity, or pre-op WOMAC, SF-12, Oxford-12 (p> 0.05). However, the AL-IM group was associated with superior outcomes (p< 0.05) in WOMAC function, WOMAC pain, global WOMAC, Oxford-12 and SF-12 physical component. In the short term the AL-IM approach provides significant improvements in quality of life scores over other limited incision approaches. It provides minimal soft tissue disruption and maintains the abductor musculature and posterior soft tissue envelope, with similar complications and radiological outcomes

Introduction: Compartment syndrome is one of the most devastating complications in orthopaedic trauma cases. The aim of this study is to investigate whether the intra-compartmental pressure changes rise and stay above the dangerous limits during percutaneous bridge plating of tibial shaft fractures necessitating fascial release or not. Patients and Methods: Between January 2007 and April 2009 17 isolated tibial fractures of the 17 patients were treated with percutaneous bridge plating technique by a single orthopaedic trauma surgeon. During the operation before, during and after the plating leg compartmental pressures were measured by using invasive blood pressure monitor. Demographic, trauma and fracture related data were also recorded. Analyses were performed by using SPSS 13. Findings: Mean age was 32 (19–55) years. Mean of ISS was 14 (10–27). Plating was performed at a mean of 3,3 (1–6) days after the trauma. Means of difference between systolic and diastolic blood pressure and leg anterior compartment pressures just before the plate insertion were 42 and 25,5 (16–32) mmHg respectively. During plating compartmental pressures rose to a mean of 51,5 mmHg (p=0,001) and dropped to 50 mmHg 10 minutes after implantation. Mean delta P was – 7 mmHg for the leg antertior compartment ten minutes after plating. No correlation was found between the blood pressure differences; ISS; age; type of anesthesia and delta P (r< 0,1 and p> 0,05). Although there is a trend of having decreased delta P with earlier surgery difference was not significant (r=0,18; p=0,058). Conclusion: Anterolateral percutaneous bridge plating of tibial shaft fractures significantly increases intracom-partmental pressures. Physician should carefully judge the risk of compartment syndrome in each patient separately and should not hesitate to perform percutaneous fascial release intraoperatively

Introduction: This single incision, anterolateral intermuscular approach (AL-IM) utilizes the interval between gluteus medius and tensor fascia lata. The aims of the study were to compare the quality of life, satisfaction and complications of this approach with two of the most commonly used limited incision transmuscular (TM) approaches, namely the mini-posterior (P-TM) and the mini-direct lateral (L-TM). Methods: 199 patients receiving MIS THA surgical procedures were evaluated prospectively (63 AL-IM, 68 P-TM and 68 L-TM). The outcome variables were WOMAC function, pain, stiffness, SF-12 (physical & mental), Oxford-12, satisfaction and radiological outcome. Parametric and non-parametric analyses were performed. Results: There were no significant differences between groups in baseline characteristics including age, sex, BMI, co-morbidity, or pre-op WOMAC, SF-12, Oxford-12 (p> .05). However, the AL-IM group was associated with superior outcomes (p< .05) in WOMAC function, WOMAC pain, global WOMAC, Oxford-12 and SF-12 physical component. Conclusion: In the short term the AL-IM approach provides significant improvements in quality of life scores over other limited incision approaches. It provides minimal soft tissue disruption and maintains the abductor musculature and posterior soft tissue envelope, with similar complications and radiological outcomes

Introduction: Total hip arthroplasty preformed with the use of minimal incision surgery has received tremendous attention recently. Various surgical approaches have been introduced to minimize surgical trauma to the soft tissues. The mini invasive Modified Watson-Jones approach have been selected to decrease the perioperative complications associated with other mini invasive approaches that has been described. The anterolateral mini incision is a new innovative approach using the intramuscular plan between the gluteus medius and the tensor fascia lata. This intermuscular interval through a small incision provides good exposure and preserves muscle integrity. Moreover, preserving the muscle integrity provides a very stable joint after implantation such that no restrictions is giving to the patient during the rehabilitation period. Materials and Methods: Between July 2004 to September 2005, we used this approach on 60 sequential patients. Fifty patients were enrolled in this prospective study. Patients were evaluated preoperatively, immediately postoperatively, and at 3-month and 6 month follow-up according to operating time, intraoperative blood loss, subcutaneous drains blood loss, post op pain control drugs requirements, short form 36 patient questionnaire (SF-36) scores and the Harris Hip Score (HHS). 4 patients had previous THA on the contralteral side. Results: The average operation time was 137min (range 90–200min), there were no dislocations, the mean post operation blood transfusion requirements was 1.64, the mean subcutaneous drains blood loss was 241.9ml (range 20–620ml), there was significant improvement in function, pain, SF-36 and Harris Hip Score (HHS) at the 3-month and 6-month follow-up examination. The average length of the incision was under 12cm. We had one reoperation due to deep infection. All four patients with bilateral THA preferred their last operation due to lack of post operative restrictions and due to shorter recovery of muscle strength. Conclusion: We think that using mini invasive Modified Watson-Jones approach in total hip replacement surgeries is a preferable option. There are several advantages of using this approach compared with the more traditional techniques. Such a technique should help reduce morbidity and complication rates for those patients undergoing a total hip replacement

In fall 2004 we started with minimal invasive hip surgery at our clinic. Our requirements: Use of our standard implant system (Bicon threaded cup and Zweymüller stem), fast realization of the minimal invasive procedure through the continuation of the used, anterolateral Watson-Jones approach, modified for this technique, retaining the supine position with unchanged orientation concerning the positioning of the implant parts. Our expectations: Reduction in operative trauma through lower blood loss with less post-operative pain, less limping especially during the first weeks, less trochanter pain through the preservation of the gluteal muscle tendons, fewer posterior dislocations by preservation of the dorsal capsule, and a better cosmetic result. The patient is placed in supine position on the standard OR table with the option of tilting the legs down. The contralateral leg lies on a leg holder in extended position, flexed by approx. 20 degrees. This allows to bring the leg in hyperextension (without hyperlordosis of the lumbar spine), adduction and external rotation during broaching the femur. The main criterion of the minimal invasivness is the preservation of the gluteal tendons and not primarily the reduction of the length of the skin incision. An extensive capsular release with partial dissection of the rectus tendon for exposure of the acetabulum is necessary. For the stem implantation a notching of the piriformis can be necessary in addition to this. During the stem preparation the soft tissues should not influence the axial entrance of the rasps into the femoral canal otherwise there is a danger of a dorsolateral perforation. Right-left-lateral-double-offset rasps and the use of manipulation rasps as trial prostheses have worked satisfactorily. Retrospective analyses of numerous peri- and post-operative data were accomplished, as well as radiological evaluations regarding the optimal position of the implanted joints, and compared with a conventional control group. After a learning curve the OP duration was the same in both groups. The development of the haemoglobin and hematocrit levels were identical, 1/3 of the patients needed blood subsitution (autologous or stored blood). 90% of the analysed postoperative x-rays in standing position showed equal bilateral leg length corresponding to the preoperative planning, the planned offset was achieved in 93%. Deviations of the remaining were without clinical relevance. The complication rate was 2,5%. Conclusions: The anterolaterale approach in supine position is standardised for the minimal invasive THR. The compliance with the developed implantation technique is a requirement for the optimal positioning of the prosthesis and to avoid complications. The subjective patient assessments, especially of those who experienced both methods, are impressive