Application of a modified surgical position in anterior approach for total cervical artificial disc replacement

BACKGROUND Total cervical artificial disc replacement(TDR)has been considered a safe and effective alternative surgical treatment for cervical spondylosis and degenerative disc disease that have failed to improve with conservative methods.Positioning the surgical patient is a critical part of the procedure.Appropriate patient positioning is crucial not only for the safety of the patient but also for optimizing surgical exposure,ensuring adequate and safe anesthesia,and allowing the surgeon to operate comfortably during lengthy procedures.The surgical posture is the traditional position used in anterior cervical approach;in general,patients are in a supine position with a pad under their shoulders and a ring-shaped pillow under their head.AIM To investigate the clinical outcomes of the use of a modified surgical position versus the traditional surgical position in anterior approach for TDR.METHODS In the modified position group,the patients had a soft pillow under their neck,and their jaw and both shoulders were fixed with wide tape.The analyzed data included intraoperative blood loss,position setting time,total operation time,and perioperative blood pressure and heart rate.RESULTS Blood pressure and heart rate were not significantly different before and after body positioning in both groups(P>0.05).Compared with the traditional position group,the modified position group showed a statistically significantly longer position setting time(P<0.05).However,the total operation time and intraoperative blood loss were significantly reduced in the modified position group compared with the traditional position group(P<0.05).CONCLUSION The clinical outcomes indicated that total operation time and intraoperative blood loss were relatively lower in the modified position group than in the traditional position group,thus reducing the risks of surgery while increasing the position setting time.The modified surgical position is a safe and effective method to be used in anterior approach for TDR surgery.

Dissection and ligation of the lateral circumflex femoral artery is not necessary when using the direct anterior approach for total hip arthroplasty

BACKGROUND Branches of the lateral circumflex femoral artery(LCFA) stretch across the surgical field during a direct anterior total hip arthroplasty. It is an anatomical marker in direct anterior approach. As an important vessel around the hip joint,this vessel was ligated in most situations. Although ligation of the vascular pedicle of the LCFA is a common, traditional procedure used to decrease bleeding, the ligation of the pedicle of the vessel is tedious and time-consuming.AIM To explore whether this ligation is truly necessary in a direct anterior approach to total hip arthroplasty.METHODS This single-center, single-surgeon, prospective study was performed to compare patients' bleeding undergoing ligation of the branches of the LCFA pedicle(group A) vs those treated with electrocautery from the branches of the LCFA(group B). In both groups, the pedicles were identified in the intermuscular plane between the tensor fasciae lata and the rectus femoris muscles. In group A, the pedicles were ligated with a silk ligature. In group B, the branches coming off the LCFA were controlled with electrocautery. We compared preoperative vs postoperative changes in blood hemoglobin levels, intraoperative blood loss,operative time, rates of transfusion, re-bleeding, and hematoma between the two groups.RESULTS The reduction of hemoglobin in group A was 20.9 ± 7.0, and in group B it was 21.2 ± 4.9. There was no statistically significant difference between the two groups(P > 0.05). The actual calculated blood loss in group A was 784 ± 125 mL,and in group B it was 722 ± 153 mL. There was a trend in group A having more blood loss(P = 0.078). The estimated blood loss in group A was 344 ± 88 mL, and in group B it was 346 ± 73 mL. There was no statistically significant difference between the two groups(P = 0.883). In addition, there were no significant differences in the rates of postoperative transfusion(10% vs 6.7%, P > 0.05),postoperative hematomas(6.7% vs 13.3%, P > 0.05), or re-bleeding(13.3% vs 20%,P > 0.05) between the two groups.CONCLUSION Ligation of the pedicle of the LCFA has no advantage in preventing or decreasing bleeding during or after a total hip arthroplasty using the direct anterior approach. Ligation of the pedicle of the vessel is a cumbersome, unnecessary procedure and can be replaced by electrocautery control of the branches off this artery that course through the surgical field.

Taper-wedge stem suitable for anterior approach total hip arthroplasty:Adequate biomechanical reconstruction parameters and excellent clinical outcome at mid-term follow-up

BACKGROUND The direct anterior approach(DAA) for total hip arthroplasty(THA) is a less invasive and muscle-sparing approach that seems to improve early function and patient satisfaction. Several studies, however, have reported high complication and revision rates due to the technical difficulties related to the femoral preparation.AIM To evaluate the usefulness and safety of a new stem equipped with a morphometric design and a size-specific medial curvature in DAA for THA.METHODS This retrospective study was based on 130 patients that underwent mini-invasive DAA procedures for THA using the Accolade Ⅱ stem. A total of 144 procedures were included in the assessment, which was based on postoperative complications, survival rates, functional parameters, and patient related outcomes.RESULTS Overall complications were recorded in 6 procedures(4.2%). There were no complications related to the stem implantation and no intraoperative fractures. Only one patient was revised for deep infection. On radiographs, biomechanical hip reconstruction was satisfactory and no stem showed any subsidence greater than 2 mm. Full osseointegration based on Engh scores was seen in all of the implanted stems. Median Harris hip score at final follow-up was 99 points(range 44-100 points), which resulted excellent in 91.3% of patients. The median values of the osteaorthritis outcome score ranged from 87.5 to 95.CONCLUSION The mid-term positive outcomes and low complication rate in our consecutive series of patients support the safety and suitability of this new stem design in DAA for THA.

Direct anterior approach hip arthroplasty:How to reduce complications-A 10-years single center experience and literature review

BACKGROUND The direct anterior approach for total hip arthroplasty(DAA-THA)is increasing in popularity due to some advantages such as less surgical trauma,minimal dissection of soft tissues,shorter rehabilitation times,faster return to daily activities,lower incidence of dislocation.On the other hand,the literature reports a high rate of intraoperative complications,with many different rates and complication types in the published papers.AIM To analyze our complications comparing results with the literature;to report measures that we have taken to reduce complications rate.METHODS All DAA-THA patients with one year minimum follow up who were operated at a single high-volume centre,between January 2010 and December 2019 were included in this retrospective study.All surgeries were performed using cementless short anatomical or straight stems and press fit cups.Patients’followup was performed,at 6 wk,3 mo,then annually post-surgery with clinical and radiological evaluation.Primary outcomes were stem revision for aseptic loosening and all-cause stem revision.Second outcome was intra-operative and post-operative complications identification.RESULTS A total of 394 patients underwent DDA-THA from January 2010 and December 2019,for a total of 412 hips;twelve patients lost to follow-up and one patient who died from causes not related to surgery were excluded from the study.The average age at the time of surgery was 61 years(range from 28 to 78 years).Mean follow-up time was 64.8 mo(range 12-120 mo).Seven stems were revised.One cortical perforation,one trochanteric and lateral cortical wall intraoperative fracture,one diaphyseal fracture,three clinically symptomatic early subsidence and one late aseptic loosening.We also observed 3 periprosthetic fractures B1 according to the Vancouver Classification.Other minor complications not requiring stem revision were 5 un-displaced fractures of the calcar region treated with preventive cerclage,one early infection,one case of late posterior dislocation,18 case of asymptomatic stem subsidence,6 cases of lateral cutaneous femoral nerve dysesthesia.CONCLUSION DAA is associated to good outcomes and lower incidence of dislocation.Complication rate can be reduced by mindful patient selection,thorough preoperative planning,sufficient learning curve and use of intraoperative imaging.

Reliability of a simple fluoroscopic image to assess leg length discrepancy during direct anterior approach total hip arthroplasty

BACKGROUND Direct anterior approach(DAA)total hip arthroplasty(THA)in a supine position provides a unique opportunity to assess leg length discrepancy(LLD)intraoperatively with fluoroscopy.Reported fluoroscopic techniques are useful but are generally complicated or costly.Despite the use of multiple techniques for leg length assessment,LLD continues to be a major post-operative source of patient dissatisfaction further emphasizing the importance of near-anatomic restoration.The utility of an alternative direct measurement of LLD on an intra-operative fluoroscopic pelvic image during DAA THA has not been reported.AIM To determine the reliability of a novel simple intra-operative measurement of LLD using a parallel line technique on a single fluoroscopic digital image of the pelvis.METHODS One hundred and seventy-one patients who underwent DAA THA were included for analysis.Intra-operative fluoroscopic and post-operative anterior-posterior radiographs were imported to TraumaCad and calibrated for LLD measurement.LLD was measured on each image using the right-left hip differences in lesser trochanter to pelvic reference line distances.Pelvic reference points included the teardrops and ischia.Fluoroscopic LLD was compared to the gold-standard measurement of LLD measured on a post-operative radiograph.RESULTS Mean absolute difference in teardrop referenced LLD between fluoroscopic and post-operative radiographs was 2.17 mm and based on the ischia mean absolute difference was 2.63 mm.Linear regression of fluoroscopic and post-operative radiograph LLD based on teardrop and ischia LLD found r2 values of 0.57 and 0.84,respectively.Mean absolute difference between fluoroscopic and postoperative x-ray LLD was within 5 mm in 95%of cases regardless of pelvic reference.CONCLUSION This study demonstrates that a single fluoroscopic view obtained during DAA THA for leg length assessment is clinically useful.

Anatomical and Clinical Implication of Corona Mortis in the Anterior Approaches of Pelvis in Sudanese Patient

Background: Corona Mortis is an abnormal blood vessels connecting Between obturator and external iliac systems of vessels and inferior epigastric vessels. It is located behind the superior public ramus at a variable distance from the symphysis pubis. Orthopaedic surgeons and obestitrtion found these vessels in the field of surgery. So displaced fractures or iatrogenic injury, can cause life threatening bleeding and hence these vascular anomalies are referred to us crown of death. The bulk of the studies about the corona mortise were conducted in the cadavers or 3D CT angiography and there was no studies were conducted about corona mortise in Sudan. The purpose of this study was to study the corona mortis anatomical and clinical implication in the anterior approaches to the pelvis and acetabulum in Sudanese patient. Methodology: Hospital based descriptive cross-sectional study was conducted among patients sustaining anterior pelvic anterior acetabulum fracture and underwent open reduction internal fixation by reconstruction plates. This study was conducted in Bahri Teaching Hospital from June 2017 to June 2018. Through the most common anterior approaches to the pelvis and acetabulum (Stoppa-modified stoppa-ilioinguinal), done by single surgeon and fulfil data sheet intra-operatively. Results: In a total of 30 pelvic halves corona mortis was detected in 13 patients (43%).The Majority in the Rt.hemipelvies 7 (53.8%) specimens: arterial 4/13 (30.8%), venous 1/13 (7.7%) and both arterial and venous in 8/13 (61.5%) specimens respectively. Of these (53.9%) had a large Diameter > 5 mm and the largest one measure 80 mm, with mean distance From the symphysis 5.8 + 1.6 mm. Conclusion: Only 13 patients have corona mortis, 12 of them were arterial with diameter more than 5 mm (53%), and thus surgeon should exercise caution during Surgery and secure its site to help minimizing surgery time, Clear surgical field and prevent iatrgenic injury.

Development of a Retractor Holding Device to Reduce the Manpower in Total Hip Arthroplasty through Direct Anterior Approach

Direct anterior approach (DAA) for total hip arthroplasty (THA) is a minimally invasive technique. In this approach, two assistants are necessary. We developed a retractor holding device called “Spider arm” to replace an assistant in the contra-lateral side. In this study, we investigated the usefulness of Spider arm in THA through direct anterior approach. 20 hips were operated without Spider arm and 21 hips were operated with Spider arm. The surgery time and the blood loss were compared. The cup position and leg length discrepancy were measured on radiography. There was no statistical significance between two groups in all parameters. No clinical complications were reported. With Spider arm, DAA-THA could be performed by two surgeons without deterioration of the surgery time and blood loss. The accuracy of cup position and leg length discrepancy was not affected. Spider arm can contribute to reducing the manpower in DAA-THA.

Surgical treatment of lower lumbar fracture with mini-incision via retroperitoneal anterior approach

Objective To investigate the clinical effects of surgical treatment of lower lumbar fracture with mini-incision via retroperitoneal anterior approach. Methods The data of 21 cases with serious lower lumbar burst fracture were analyzed retrospectively.

Decompression via posterior-anterior approach and anterior fixation in treatment of fracturedislocation of the lower cervical spine with bilateral facet joints dislocation

Objective To evaluate surgical strategy of decompression via posterior-anterior approach and anterior fixation in treatment fracture-dislocation of lower cervical spine with bilateral facet joints dislocation. Methods This

Bipolar hemiarthroplasty for femoral neck fracture using the direct anterior approach

AIM: To evaluate whether walking ability recovers early after bipolar hemiarthroplasty(BHA) using a direct anterior approach.METHODS: Between 2008 and 2010, 81 patients with femoral neck fracture underwent BHA using the direct anterior approach(DAA) or the posterior approach(PA). The mean observation period was 36 mo. The age, sex, body mass index(BMI), time from admission to surgery, length of hospitalization, outcome after discharge, walking ability, duration of surgery, blood loss and complications were compared. RESULTS: There was no significant difference in the age, sex, BMI, time from admission to surgery, length of hospitalization, outcome after discharge, duration of surgery and blood loss between the two groups. Two weeks after the operation, assistance was not necessary for walking in the hospital in 65.0% of the patients in the DAA group and in 33.3% in the PA group(P < 0.05). As for complications, fracture of the femoral greater trochanter developed in 1 patient in the DAA group and calcar crack and dislocation in 1 patient each in the PA group.CONCLUSION: DAA is an approach more useful for BHA for femoral neck fracture in elderly patients than total hip arthroplasty in terms of the early acquisition of walking ability.

Acute compartment syndrome of the thigh following hip replacement by anterior approach in a patient using oral anticoagulants

Acute compartment syndrome(ACS) of the thigh following primary total hip arthroplasty(THA) is a highly uncommon complication and has not yet been reported before with regards to the anterior approach through the anterior supine interval. We present a case of a 69-year-old male patient with a history of stroke, who developed ACS of the thigh after elective THA while using therapeutic low molecular weight heparin as bridging for regular oral anticoagulation. ACS pathogenesis, diagnostic tools, treatment and relevant literature are discussed. The patient's ACS was recognized in time and treated by operative decompression with fasciotomy of the anterior compartment. Follow-up did not show any neurological deficit or soft-tissue damage.

Direct anterior compared to posterior approach for hip hemiarthroplasty following femoral neck fractures

The differences in complication rates between the direct anterior and posterior approaches for hemiarthroplasty in elderly patients with femoral neck fractures are not yet fully understood.Dislocation,a severe complication associated with increased mortality and often requiring additional surgery,may occur less frequently with the direct anterior approach compared to the posterior approach.Careful consideration of patient demographics is essential when planning the surgical approach.Future research in this area should focus on robust randomized controlled trials involving elderly patients recovering from femoral neck fractures.

Complication rates after direct anterior vs posterior approach for hip hemiarthroplasty in elderly individuals with femoral neck fractures

BACKGROUND Dislocation rates after hemiarthroplasty reportedly vary from 1%to 17%.This serious complication is associated with increased morbidity and mortality rates.Approaches to this surgery are still debated,with no consensus regarding the superiority of any single approach.AIM To compare early postoperative complications after implementing the direct anterior and posterior approaches(PL)for hip hemiarthroplasty after femoral neck fractures.METHODS This is a comparative,retrospective,single-center cohort study conducted at a university hospital.Between March 2008 and December 2018,273 patients(a total of 280 hips)underwent bipolar hemiarthroplasties(n=280)for displaced femoral neck fractures using either the PL(n=171)or the minimally invasive direct anterior approach(DAA)(n=109).The choice of approach was related to the surgeons’practices;the implant types were similar and unrelated to the approach.Dislocation rates and other complications were reviewed after a minimum followup of 6 mo.RESULTS Both treatment groups had similarly aged patients(mean age:82 years),sex ratios,patient body mass indexes,and patient comorbidities.Surgical data(surgery delay time,operative time,and blood loss volume)did not differ significantly between the groups.The 30 d mortality rate was higher in the PL group(9.9%)than in the DAA group(3.7%),but the difference was not statistically significant(P=0.052).Among the one-month survivors,a significantly higher rate of dislocation was observed in the PL group(14/154;9.1%)than in the DAA group(0/105;0%)(P=0.002).Of the 14 patients with dislocation,8 underwent revision surgery for recurrent instability(posterior group),and one of them had 2 additional procedures due to a deep infection.The rate of other complications(e.g.,perioperative and early postoperative periprosthetic fractures and infection-related complications)did not differ significantly between the groups.CONCLUSION These findings suggest that the DAA to bipolar hemiarthroplasty for patients with femoral neck fractures is associated with a lower dislocation rate(<1%)than the PL.

Debate on direct-anterior vs posterior approach for hip hemiarthroplasty:The authors’insights

We read and discussed the study entitled“Complication rates after direct anterior vs posterior approach for Hip Hemiarthroplasty in elderly individuals with femoral neck fractures”with great interest.The authors have done justice to the topic of comparison of anterior and posterior surgical approaches for bipolar hemiarthroplasty which has been an everlasting debate in the existing literature.However,there are certain aspects of this study that need clarification from the authors.

Anterior vs conventional approach right hepatic resection for large hepatocellular carcinoma:A systematic review and meta-analysis

AIM To compare the clinical outcomes of right hepatectomy for large hepatocellular carcinoma via the anterior and conventional approach.METHODS We comprehensively performed an electronic search of Pub Med, EMBASE, and the Cochrane Library for randomized controlled trials(RCTs) or controlled clinical trials(CCTs) published between January 2000 and May 2017 concerning the anterior approach(AA) and the conventional approach(CA) to right hepatectomy. Studies that met the inclusion criteria were included, and their outcome analyses were further assessed using a fixed or random effects model.RESULTS This analysis included 2297 patients enrolled in 16 studies(3 RCTs and 13 CTTs). Intraoperative blood loss [weighted mean difference =-255.21; 95% confidence interval(95%CI):-371.3 to-139.12; P < 0.0001], intraoperative blood transfusion [odds ratio(OR) = 0.42; 95%CI: 0.29-0.61; P < 0.0001], mortality(OR = 0.59; 95%CI: 0.38-0.92; P = 0.02), morbidity(OR = 0.77; 95%CI: 0.62-0.95; P = 0.01), and recurrencerate(OR = 0.62; 95%CI: 0.47-0.83; P = 0.001) were significantly reduced in the AA group. Patients in the AA group had better overall survival(hazard ratio [HR] = 0.71; 95%CI: 0.50-1.00; P = 0.05) and disease-free survival(HR = 0.67; 95%CI: 0.58-0.79; P < 0.0001) than those in the CA group.CONCLUSION The AA is safe and effective for right hepatectomy for large hepatocellular carcinoma and could accelerate postoperative recovery and achieve better survival outcomes than the CA.

Anterior muscle sparing approach for total hip arthroplasty

The purpose of this review is to examine the validity of positive claims regarding the direct anterior approach(DAA) with a fracture table for total hip arthroplasty. Recent literature regarding the DAA was searched and specific claims investigated including improved early outcomes, speed of recovery, component placement, dislocation rates, and complication rates. Recent literature is positive regarding the effects of total hip arthroplasty with the anterior approach. While the data is not definitive at present, patients receiving the anterior approach for total hip arthroplasty tend to recover more quickly and have improved early outcomes. Component placement with the anterior approach is more often in the "safe zone" than with other approaches. Dislocation rates tend to be less than 1% with the anterior approach. Complication rates vary widely in the published literature. A possible explanation is that the varianceis due to surgeon and institutional experience with the anterior approach procedure. Concerns remain regarding the "learning curve" for both surgeons and institutions. In conclusion, it is not a matter of should this approach be used, but how should it be implemented.

Total Spondylectomy of C2 and Circumferential Reconstruction via Combined Anterior and Posterior Approach to Cervical Spine for Axis Tumor Surgery

As a result of the complex anatomy in upper cervical spine, the operative treatment of axis neoplasms is always complicated. Although the procedure for the second cervical vertebra （C2） surgery had been described previously in diverse approaches and reconstruction forms, each has its own limita- tions and restrictions that usually result in less satisfactory conclusions. The purpose of this study was to evaluate the operation efficacy for axis tumors by using a combined anterior （retropharyngeal） cervical and posterior approach in achieving total resection of C2 and circumferential reconstruction. Eight con- secutive C2 tumor patients with mean age of 47.6 years in our institute sequentially underwent vertebra resection and fixation through aforementioned approach from Jan. 2006 to Dec. 2010. No surgical mor- tality or severe morbidity occurred in our group. In terms of complications, 2 cases developed transient difficulty in swallowing liquids （one of them experienced dysphonia） and 1 developed cerebrospinal fluid leakage （CSFL） that was resolved later. During a mean follow-up period of 31.9 months, the visual analogue scale （VAS） and Japanese orthopedic association （JOA） score revealed that the pain level and neurological function in all patients were improved postoperatively, and there was no evidence of fixa- tion failure and local recurrence. It is concluded that the anterior cervical retropharyngeal approach permits a visible exposure to facilitate the C2 vertebra resection and perform an effective anterior re- construction at the same time. The custom-made mesh cage applied in our cases can be acted as a firm and convenient implant in circumferential fixation.

Anterior vs conventional approach hepatectomy for large liver cancer:A meta-analysis

AIM:To evaluate the clinical outcomes and safety of anterior-and conventional-approach hepatectomy for patients with large liver tumors.METHODS:Pub Med,EMBASE,Google Scholar and the Cochrane Library databases were searched for randomized controlled trials(RCTs)and controlled clinical trials comparing anterior-approach hepatectomy(AAH)and conventional-approach hepatectomy(CAH).Two observers independently extracted the data using a spreadsheet and assessed the studies for inclusion.Studies that fulfilled the inclusion criteria and addressed the clinical questions of this analysis were further assessed using either fixed effects or random effects models.RESULTS:Two RCTs and six controlled clinical trials involving 807 patients met the predefined inclusion criteria.A total of 363 patients underwent AAH and 444underwent CAH.Meta-analysis indicated that the AAH group had fewer requirements for transfusion(OR=0.37,95%CI:0.21-0.63),less recurrence(OR=0.57,95%CI:0.37-0.87),and lower mortality(OR=0.29,95%CI:0.13-0.63).There were no significant differences between AAH and CAH with regard to perioperative complications(OR=0.94,95%CI:0.58-1.51),intraoperative tumor rupture(OR=0.98,95%CI:0.40-2.40),or length of hospital stay(weighted mean difference=-0.17,95%CI:-2.36-2.02).CONCLUSION:AAH has advantages of decreased transfusion,mortality and recurrence compared to CAH.It is a safe and effective method for large cancers requiring right hepatectomy.

Anterior transhepatic approach for total caudate lobectomy including spigelian lobe,paracaval portion and caudate process:A Brazilian experience

To the Editor:Nowadays,because of the infiltration of cholangiocarcinoma to the parenchyma and/or bile ducts of the caudate lobe,the inclusion of caudate lobe combined with a major hepatectomy remains the gold standard approach for a resectable hilar cholangiocarcinoma.Since the last years of the 20th century,some authors have begun to report isolated caudate lobe resection for hepatocellular

Video-Assisted Anterior Retroperitoneal Approach to the Lumbar Spine. A Minimal Invasive Technique Improved by the Use of Endoscopic Camera to Treat Lumbar Spine Diseases

The anterior retroperitoneal approach is a technique to treat disc degenerative disease (DDD), spinal deformities, traumas, tumors and infections. It can be used to perform Anterior Lumbar Interbody Fusions (ALIF) or Total Disc Replacements (TDR). Though being a fast procedure that is becoming more often used by spinal surgeons, the anterior approach requires an adequate knowledge of the anatomy of the abdomen to lessen the risks of intraoperative complications. The authors’ preferred technique is the left retroperitoneal video-assisted approach, using an endoscope to visualize and magnify the deep anatomical structures, discectomy procedure and hardware implant. In a review of our casuistry from 2010 to 2012, 163 patients underwent an anterior lumbar approach, and 139 of these had a single L4-5 or L5-S1 level treatment. A 3.6% rate of global complications (1.44% of major vascular injuries) has been observed, with a mean operation time of 116.4 minutes and a mean blood loss of 156.1 ml. These values show how the anterior retroperitoneal video-assisted approach for the treatment of lumbar diseases is a fast procedure that implies low blood loss, with a low rate of intraoperative complications.