Introduction. Although various reports analyzed “en-bloc” excision of sacral tumors, there are still technical problems to improve protection of nerve roots, preserve surrounding structures and reduce intraoperative bleeding, maintaining the oncologic result. We present a new technique for sacral resection, with short term preliminary results, derived with modification from Osaka technique. Methods. Seven patients were resected for their sacrococcygeal chordoma with the followed described technique. Two patients had previous surgery elsewhere. The sacrum is exposed by a posterior midline incision and complete soft-tissue dissection. Lateral osteotomies were performed through the sacral foramina using a threadwire saw and Kerrison rongeurs, to avoid sacral roots damage. After proximal osteotomy, the sacrum is laterally elevated and mobilized to allow dissection of presacral structures. Mean surgical time was 5 hours (range: 3 to 8). Mean blood loss was 3640 ml. Results. Level of resection was S1 in 2 pts, S2 in 4 pts, S3 in 1. Margins were wide in 6 patients and marginal in one. At a mean follow-up of 2 years, six patients were disease-free, one had a local recurrence. No complications were showed. Conclusion. This technique allows wide margins with roots preservation and reduction of complications and operative time. Indications for posterior approach only can be extended to resection proximal to S3, when there is minimal pelvic invasion and none or partial involvement of sacroiliac joints. However, the long term benefits of this technique need to be evaluated

Our unit historically performed total hip replacement (THR) through either posterior or anterolateral approaches. In November 2020 a group of 5 consultants transitioned to utilising the Direct Anterior Approach (DAA). Appropriate training was undertaken and cases were performed as dual consultant procedures with intraoperative radiography or robotic assistance. Outcomes were collated prospectively. These included basic demographics, intraoperative details, complication rates and Oxford Hip Scores. A total of 48 patients underwent DAA THR over 1 year. Mean age was 67 and ASA 2. Over this time period 140 posterior approach and 137 anterolateral approach THR's were performed with available data. Propensity score matching was performed on a 1:1 basis using BMI, Age, Sex and ASA as covariates to generate a matched cohort group of conventional approach THR (n=37). Length of stay was significantly reduced at 1.95 days (p<0.001) with DAA compared to Anterolateral and Posterior approach. There was no significant difference with length of surgery, blood loss, Infection, dislocation and periprosthetic fracture rate. There was no significant difference in Oxford Hip Score between any approach at 3 months or 1 year. The transition to this approach has not made a negative impact despite its associated steep learning curve, and has improved efficiency in elective surgery. From our experience we would suggest those changing to this approach receive appropriate training in a high-volume centre, and perform cases as dual consultant procedures

Aims. Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort. Methods. We have prospectively monitored a series of 22 cases (21 patients) with a mean follow-up of 32 months (13 to 59). Results. The mean patient age was 79 years (67 to 87), and the mean ASA score was 3.3 (3 to 5). Three patients had high-energy injuries and 18 had low-energy injuries. All cases were associated fractures (Letournel classification: anterior column posterior hemitransverse, n = 13; associated both column, n = 6; transverse posterior wall, n = 3) with medialization of the femoral head. Mean operative time was 93 minutes (61 to 135). There have been no revisions to date. Of the 21 patients, 20 were full weight-bearing on day 1 postoperatively. Mean length of hospital stay was 12 days (5 to 27). Preoperative mobility status was maintained in 13 patients. At one year, mean Merle d’Aubigné score was 13.1 (10 to 18), mean Oxford Hip Score was 38.5 (24 to 44), mean EuroQol five-dimension five-level (EQ-5D-5L) health score was 68 (30 to 92), and mean EQ-5D-5L index score was 0.68 (0.335 to 0.837); data from 14 patients. Mortality was 9.5% (2/21) at one year. There have been no thromboembolic events, deep infections, or revisions. Conclusion. The coned hemipelvis reconstruction bypasses the fracture, creating an immediately stable construct that allows immediate full weight-bearing. The posterior approach minimizes the operative time and physiological insult in this vulnerable patient population. Early results suggest this to be a safe addition to current surgical options, targeted at the most medically frail elderly patient with a complex displaced acetabular fracture. Cite this article: Bone Joint J 2020;102-B(2):155–161

The posterior approach to the hip avoids violating abductors and has presumed functional advantages. The anterolateral approach risks abductor damage, but has reportedly lower dislocation rate. To determine effects of surgical approach on function and dislocation after primary and revision THR 3274 primary THRs and 66 first time revision THRs were investigated from the arthroplasty database (2000–2008). 2682 (82%) primary THRs were via anterolateral approach, 592 (18%) by posterior. Post primary dislocation rate was 50/2682 (1.9%) for anterolateral and 26/592 (4.4%) for posterior. Posterior approach had significantly better Harris Hip Scores: 91 vs 88 (P = 0.000) and function: 40 vs 37 (P = 0.000). Of the 66 revisions THRs, 30 were anterolateral and 36 posterior. Dislocation rates were 2/30 (6.7%) and 4/36 (11.1%) respectively. There was no significant difference in Harris Hip Score or Harris Hip Function 1 year after revision based on revision surgery approach. However there was a significant difference in Harris Hip Function 1 year after revision based on the approach for primary surgery (Anterolateral 30 vs Posterior 37, P=0.008) and a similar trend in Harris Hip Score (Anterolateral 79 vs Posterior 85, P = 0.198) and patients who had posterior approach for both primary and revision had the best scores overall. The clinical relevance of the modest, but statistically significant difference in Harris hip score after primary THR is unclear. That primary approach has an impact on function after revision suggests the posterior approach should be considered in younger patients likely to require revision in the future

The optimal approach for total hip arthroplasty (THA) remains controversial. We present the results of the Direct Superior Approach (DSA), an improved variation of the posterior approach with high levels of stability, patient-reported functional outcomes, and satisfaction. This is a single-surgeon prospective series. All patients undergoing THA between 2010 and 2015 via the DSA were included. Complication data was collected by interrogation of the Scottish Arthroplasty Project national joint registry. Pre and one-year post-operative Oxford Hip Score (OHS), Euroqol-5D (EQ-5D), and patient satisfaction questionnaires were collected. 659 patients received a THA via the DSA during the study period. Average age was 61.8 years (range 16.4–93.3). Analysis of registry data revealed no cases of dislocation, 5 cases of venous thromboembolism (0.75%), and 5 cases of deep infection (0.75%). 586 patients (88.9%) underwent their surgery in the National Health Service, and post-operative outcomes were available for 337 of these patients (57.5% follow-up) at one year. Average improvement in OHS and EQ-5D was 20 (range −14 – 48) and 0.39 (−0.697–1.2) respectively. 311 patients (92.3%) were satisfied. This description of the DSA is accessible to all surgeons, confers excellent stability with no dislocations, and is associated with excellent post-operative functional outcomes and patient satisfaction

Aims. Hemiarthroplasty of the hip is usually carried out through either a direct lateral or posterior approach. The aim of this prospective observational study was to determine any differences in patient-reported outcomes between the two surgical approaches. . Patients and Methods. From the Swedish Hip Arthroplasty Register we identified patients of 70 years and above who were recorded as having had a hemiarthroplasty during 2009. Only patients who had been treated with modern prostheses were included. A questionnaire was posted to those who remained alive one year after surgery. A total of 2118 patients (78% of those available) with a mean age of 85 years (70 to 102) returned the questionnaire. . Results. Patients who had undergone surgery through a posterior approach reported a higher health-related quality of life (HRQoL, EQ-5D mean 0.52 versus 0.47, p = 0.009), less pain (visual analogue scale mean 17 versus 19, p = 0.02) and greater satisfaction with the result of surgery (visual analogue scale mean 22 versus 24, p = 0.02) than those who had a direct lateral approach. However, after adjusting for age, gender, cognitive impairment and American Society of Anesthesiologists grade, no association was found between surgical approach and HRQoL, residual pain or patient satisfaction. Take home message: The surgical approach for hemiarthroplasty does not seem to affect the patient-perceived HRQoL, residual pain or patient satisfaction one year after surgery on elderly patients. The choice of approach should be based on other factors, such as the risk of dislocation. Cite this article: Bone Joint J 2016;98-B:542–7

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

Background. The long-term impact of dividing Piriformis when performing a standard posterior approach to the hip has not been assessed. A less invasive approach in which the tendon is preserved has been described (the Piriformis-sparing minimally invasive [PSMI] approach). With advances in MRI technology it is now possible to image structures in close proximity to metal without artifact. The aim of the study was to compare the MRI features (muscle grade and bulk) of the divided and repaired Piriformis tendon group (by the standard posterior approach) with the preserved tendon group (by the PSMI approach). Methods. As part of an on-going randomized controlled trial comparing the PSMI approach with the standard posterior approach for total hip replacement, a subgroup of 20 consecutive patients who fulfilled the inclusion criteria were recruited. Patients received preoperative and 3 months and 2 year postoperative MRI scans. Patients and evaluators were blinded to allocation. Outcomes assessed included grade, volume and integrity of Piriformis. Results. There was significantly less deterioration in muscle grade (p = 0.002) and bulk (p = 0.013) in the preserved Piriformis tendon group in comparison to the divided and repaired Piriformis group. There was equal deterioration in muscle grade and bulk of all divided tendons (Obturator Internus and Piriformis by the standard approach and Obturator Internus by the PSMI approach). The majority (10/11) of the Piriformis tendons by the PSMI approach were intact post-operatively. Conclusions. The PSMI approach, in which the Piriformis tendon is preserved, is successful in maintaining the integrity of the tendon as well as preventing deterioration in grade and bulk of the muscle belly

Introduction. Controversy exists as to whether the short external rotator tendons and capsule of the hip should be repaired after posterior approach primary total hip arthroplasty (THA). Recent studies using radiopaque markers have demonstrated that reimplantation of these muscle tendons fail early and may not prevent post operative dislocation. Methods. Using dynamic ultrasound examination we evaluated the patency of repair in 68 tendon groups (piriformis/conjoint tendon and obturator externus). We demonstrate short and medium term success in the reimplantation of these tendons using the double transosseous drill hole technique of reattaching the tendons and capsule to the greater trochanter. We followed up 21 of our total hip replacements and 13 hip resurfacings and undertook a dynamic ultrasound examination of the external rotators by an experienced musculoskeletal radiologist to assess their integrity at a minimum of 60 days and 100 days and an average of 213 days after the operation. Results. There were 34 hips assessed in 33 patients. 21 were total hip replacements and the rest were hip resurfacings. Each patient underwent a standard posterior approach by the senior surgeon. The piriformis and conjoint tendons (Group 1) and the obturator extenus (Group 2) were reattached with modified kessler sutures using a transosseous reimplantation technique. The capsule was reattached with a running suture using the same technique. The total hip replacement group had 16 out of 21 hips (76.2%) where both external rotator groups were intact at follow up, compared with 3 out of 13 hips (23.1%) for the hip resurfacing group (Chi-squared 9.188, p=0.002). Group 1 tendons were intact in 81% of the THR group while only in 53.8% in the rsurfaing group. We compared the hip replacement group with the hip resurfacing group using survival analysis techniques (log rank test), which take into account the different follow-up times. The hip replacement group showed a significantly longer time to the event of either rotator group not being intact at follow-up than the hip resurfacing group (log rank 5.568, p=0.018). Conclusions. Our results do appear to suggest that this technique may be of benefit in patients undergoing primary THA but may not be as successful after resurfacing procedures. We propose that the increased incidence of external rotator detachment seen in the resurfacing group may be due to the increased strain imparted on the tendons due to the greater distance to travel, as they wind around the large resurfaced femoral head and neck as compared to the relatively thinner THA femoral neck and smaller head component

Aims

The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients.

We reviewed 26 patients who had had internal fixation of an open intra-articular supracondylar fracture of the humerus. All operations were performed using a posterior approach, 13 with a triceps split and 13 with an olecranon osteotomy. The outcome was assessed by means of the Mayo Elbow score, the Disability of the Arm, Shoulder and Hand (DASH) score and the SF-36 Physical Function score. Patients with an olecranon osteotomy had less good results

Objectives. To determine the limits of spinal displacement before the onset of neurophysiological changes during spinal surgery. Assessing if the type of force applied or the section of the adjacent nerve roots increases the tolerance to displacement. Methods. Experimental study in 21 domestic pigs. Three groups were established according to the displacing force applied to the cord: separation (group 1, n=7), root stump pull (group2, n=7) and torque (group3, n=7). Successive records of cord-to-cord motor evoked potential were obtained. The displacing force was removed immediately when neurophysiological changes observed. The experiment was repeated after sectioning the adjacent nerve roots. Results. The diameter of the dura in the study area was 7.2 ± 1 mm. Group 1: evoked potential changes appeared with displacement of 10.1 ± 1.6 mm with roots unharmed and 15.3 ± 4.7 mm (p <0.01) with section of four adjacent roots. Group 2: evoked potential disturbance at 17.5 ± 4.7 mm, which increased to 23.5 ± 2.1 mm (p <0.05) after cutting the two contralateral roots. Group 3: cord allowed torque of 95.3° ± 9.2 increasing to 112.4 ° ± 7.1 ° if the contralateral roots were cut. Except in two cases in group 3 (torsion), the potentials were normalized immediately after releasing the deforming force. Discussion. This experimental study shows that it is possible to surgically displace the medulla a distance superior to the diameter of the dura without detecting neurophysiological changes. The limits of cord displacement may be increased by the section of the adjacent nerve roots and if the tensile force is applied by traction of the root stumps. These findings support the neurological safety of spine deformity correction by isolated posterior approach, obviating the morbidity related to an additional anterior procedure

Purpose. In stabilisations of atlantoaxial instabilities it holds risks to injure the A. vertebralis as well as neurological structures. Furthermore the posterior approach of the upper part of the cervical spine requires a huge and traumatic preparation of the soft tissue. However the anterior transarticular C1-2 fusion (ATF) is less traumatic and offers almost the same strengh of the stabilisation. Methods. Since the 01/2007 22 multimorbid patients with atlanto-axial instabilities of different entities were treated via the ATF, were regular examined radiologicaly (x-ray/CT) and the procedure critically judged. Results. C1-2 fusions were performed in 22 patients (17f, 5m, Ø 81,67 years). Main symptoms was pain radiating in the upper cervical spine and the occiput, 2 Patients complaining radiating pain with paraesthesia. The average operation-time took 64,5 min. Leftside the screws of Ø 39,5mm (32–44mm), rightside of 36mm (32–44mm) were inserted in addiction to the point of access and the angle of insertion (mediolateral angle Ø 32,0°, ventrodorsal Ø17,6°). No introperative complications occured, one revision had to be done because of p.o. bleeding, one because of screw dislocation. Postoperative x-ray and CT control of the upper cervical spine showed 30/44 screws in 22 patients in correct position. 8 (18,2%) screws were too long, 3 (6,8%) screws were placed too anterior and 3 (6,8%) too medial. 8 additional positionated dens-screws were in correct position. After a clear learning curve both screws of the 6th patient were positoinated correct. Two aspects are important for success: Correct entry point and right insertion of the angle in the coronar and sagittal view. A low intraoperative blood loss, a non traumatic access as well as an immediate pain decrease have to be valued positively for this procedure. Conclusions. The gentle procedure of the ATF requires-despite of the huge experience in anterior surgery of dens fractures - a learning curve, because of the more proximate insertion point, the flat insertion angle and the closeness of the A. vertebralis. If these aspects are going to be noticed, failed screw positioning and excessive length as well as injuries of the A. vertebralis can be avoided

We describe the results after open reduction and internal fixation of 22 consecutive displaced fractures of the glenoid with a mean follow-up of ten years. A posterior approach was used in 16 patients and an anterior in six, the approach being chosen according to the Ideberg classification of the fractures. The fixation failed in two patients, one of whom required a further operation. There were two cases of deep infection. At follow-up the median Constant score was 94% (mean 79%, range 17 to 100). The score was less than 50% in four patients, including the two who became infected. A further two had an associated complete palsy of the brachial plexus

Aims

The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip.

Anteriorly displaced fractures of the wrist can be treated by the Kapandji technique of percutaneous intrafocal pinning with pins inserted through an anterior approach to give good reduction and stabilisation of the fracture. We have modified this technique by placing the pins through a posterior approach which decreases the risks of neurovascular damage. We have used this method to treat six children with distal radial fractures showing anterior displacement or instability. Good anterior stabilisation was achieved. The pins were removed at an average of eight weeks and the patients were then able to return to full activity. This simple technique can be used for unstable fractures after the failure of conservative treatment or in bilateral fractures in adolescents

Aims

No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA.

BACKGROUND & AIM. Most previous studies found that the rate of dislocation following primary THA was 2 to 3 % on average. It is expected that minimally invasive (MI) THA has fewer dislocations after surgery because it causes less muscle damage. To ascertain the risk factors of dislocation, we conducted a retrospective study of the occurrence of dislocation after MI-THA in Japanese patients. METHODS. From June 2003 when we began MI-THA to August 2010 primary MI-THAs were performed on 2,042 hips; 1,997 hips with mini-posterior approach (a mean incision of 7 cm) with the repair of posterior soft tissues and 45 hips with other approaches. The dislocation after MI-THA was studied with respect to age, sex, body mass index, the use of navigation system, femoral head size, cup size and approaches. The period of follow-up was from six weeks to seven years. RESULTS. The numbers of dislocation after MI-THA were 13 hips (0.6%). The numbers of posterior and anterior dislocation after MI-THA were nine and four hips, respectively. In the patients undergoing MI-THA, there was a significant difference between non-dislocated hips and dislocated hips, with respect to the average age (57 years vs. 66 years, p<0.017), the numbers of male patients (181 cases (9%) vs. 4 cases (31%), p<0.024), cup size (50 mm vs. 53 mm, p<0.007) and the numbers of cases which used navigation system (1,932 hips (95%) vs. 10 hips (77%), p<0.023). Whereas there was no significant difference between non-dislocated hips and dislocated hips with respect to the body mass index, femoral head size and approaches. DISCUSSION. Several risk factors of the dislocation after primary THA have been reported. In this study we found that MI-THA had fewer risk of dislocation as compared with historic controls. It is suggested that less soft tissue damage can decrease the risk of the dislocation after surgery. The incidence of dislocation was fewer in the younger and female patients undergoing MI-THA with the navigation system than in the older and male patients undergoing MI-THA without the navigation system. The posterior approach combined with the repair of posterior soft tissues did not increase the risk of dislocation after surgery as compared with other approaches. The position of implants is important to prevent dislocation after surgery, and the navigation system can help to obtain a good position of implants. CONCLUSIONS. We conclude that MI-THA can decrease the risk of dislocation after primary THA. Furthermore the combination of MI-THA and the navigation system is very useful to reduce the incidence of dislocation because the use of the navigation system during surgery can be helpful to acquire the precise position of implants

The use of a total hip arthroplasty with alumina on alumina bearing couple should limit the risk of wear and secondary osteolysis. From June 1999 to December 2002, we have realised a continuous series of 265 ABGII cementless THA with Alumina bearing. The average age was 58 years (22–78 years). The main causes were osteoarthritis (81%) and osteonecrosis (13%). The operation was performed through a posterior standard approach. In all cases, an anatomic cementless ABG II stem and an acetabular cementless ABG II cup were implanted. The bearing couple was always Alumina Biolox Forte with a 28 mm femoral head in 99% of cases. To date, 12 patients died and 17 patients were lost to follow up (6.4%). 224 patients (232 hips) had a regular clinical and radiological follow-up. The mean follow up was 8.5 years (5–11 years). 9 patients were revised for septic loosening (4cases), femoral fracture (4 cases) and inveterate dislocation (1 case). There was no aseptic loosening. The overall survival rate at more than 10 years is 96.6%. We deplore 2 cases of postoperative dislocation. In this series, we did not observe any breakage of ceramic implant. The clinical and functional outcome is good and stable over time with an average PMA score at 17.6 and an average Harris score at 97.3. 16 patients reported at least one or more episode of abnormal noise “Squeaking” type (6%). It is most often a mild noise and it occurs in a static bending position. This noise disappeared with time in 10 cases. It never necessitated a prosthetic revision. The radiological control does not show any wear. There is no evidence of acetabular or femoral osteolysis. The radiological implant fixation according to the Engh and ARA criteria was good and stable in all cases. This series demonstrate that the implantation of an anatomic cementless HA arthroplasty with an alumina bearing in a young and active patient prevents the risk of wear and osteolysis and improves durability over time. The use of a 28 mm head does not increase the risk of instability and we did not observe failure of the ceramic implants

Aims

This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation.