Promising medium-term results of anterior approach with an anatomical short stem in primary hip arthroplasty

Background In the last decade, the increase in the use of the direct anterior approach to the hip has contributed to the diffusion of the use of short stems in orthopedic surgery. The aim of the study is to verify the medium-term clinical and radiographic results of a cementless anatomic short stem in the anterior approach to the hip. We also want to verify whether the use of the standard operating room table or the leg positioner can affect the incidence of pre- and postoperative complications. Materials and methods All total hip arthroplasty patients with a 1-year minimum follow-up who were operated using the MiniMAX stem between January 2010 and December 2019 were included in this study. Clinical evaluation included the Harris Hip Score (HHS), Western Ontario and McMaster Universities Hip Outcome Assessment (WOMAC) Score, and Short Form-36 (SF-36) questionnaires. Bone resorption and remodeling, radiolucency, osteolysis, and cortical hypertrophy were analyzed in the postoperative radiograph and were related to the final follow-up radiographic results. Complications due to the use of the standard operating room table or the leg positioner were evaluated. Results A total of 227 patients (238 hips) were included in the study. Average age at time of surgery was 62 years (range 38–77 years). Mean follow-up time was 67.7 months (range 12–120 months). Kaplan–Meier survivorship analysis after 10 years revealed 98.2% survival rate with revision for loosening as endpoint. The mean preoperative and postoperative HHS were 38.35 and 94.2, respectively. The mean preoperative and postoperative WOMAC Scores were 82.4 and 16.8, respectively. SF-36 physical and mental scores averaged 36.8 and 42.4, respectively, before surgery and 72.4 and 76.2, respectively, at final follow-up. The radiographic change around the stem showed bone hypertrophy in 55 cases (23%) at zone 3. In total, 183 surgeries were performed via the direct anterior approach (DAA) on a standard operating room table, and 44 surgeries were performed on the AMIS mobile leg positioner. Comparison between the two patient groups did not reveal significant differences. Conclusion In conclusion, a short, anatomic, cementless femoral stem provided stable metaphyseal fixation in younger patients. Our clinical and radiographic results support the use of this short stem in the direct anterior approach. Level of evidence IV.

Operating On a Stretcher Is a Safe Alternative to an Operating Room Table

Purpose: The primary purpose of this study was to compare intraoperative and post-operative complication rates for upper extremity surgical cases performed on a standard operating room (OR) table with similar cases done on a typical hospital stretcher. Secondary measures reviewed included surgical time, turnover time, total OR time, blood loss, tourniquet time, and postoperative complications. Methods: Using our institution’s electronic medical record system, we reviewed 100 consecutive upper extremity cases performed on a stretcher as well as 100 consecutive upper extremity cases done on a standard OR table. All cases were performed by the same board certified, fellowship trained orthopaedic surgeon. The cases were performed between February of 2014 and May of 2016 at a level one trauma center and its associated outpatient surgical center. Basic univariate statistical analyses were performed, and the two groups were compared for primary and secondary outcome measures. Results: The data showed no significant increase in intraoperative complication rates when operating on a standard hospital stretcher compared to operating on an OR table. There were a total of 6 postoperative complications in the stretcher group and a total of 11 complications in the OR table group. The most common postoperative complication seen in both cohorts was infection. There was one intraoperative complication in the OR table group and none in the stretcher group. With regard to total operating room time, surgical time, and delta time (overall OR room time minus surgical time which was used to calculate the turnover time), we found that the OR table group had shorter times in each category. The total OR time for the OR table group was a mean time of 105 minutes compared to 146 minutes seen in the stretcher group (p= 0.0002). Similarly, there was a shorter mean surgical time for surgeries done on an OR table (73 minutes) when compared to surgeries done on a stretcher (104 minutes) (p = 0.0026). Finally, the average turnover time (delta time) for the OR table group was 32 minutes while the average turnover time for the stretcher group was 42 minutes (p= 0.0002). The average tourniquet time for the OR table group was 36 minutes as compared to 41 in the stretcher group (p=0.467). Conclusion: Operating on a typical hospital stretcher is a safe alternative to operating on a standard operating room table as there was no increased complication rate seen with surgeries performed on a stretcher compared to an OR table.

Operating on a Stretcher is a Safe Alternative to An Operating Room Table

Purpose:The primary purpose of this study was to compare intraoperative and post-operative complication rates for upper extremity surgical cases performed on a standard operating room (OR) table with similar cases done on a typical hospital stretcher. Secondary measures reviewed included surgical time, turnover time, total OR time, blood loss, tourniquet time, and postoperative complications.Methods:Using our institution’s electronic medical record system, we reviewed 100 consecutive upper extremity cases performed on a stretcher as well as 100 consecutive upper extremity cases done on a standard OR table. All cases were performed by the same board certified, fellowship trained orthopaedic surgeon. The cases were performed between February of 2014 and May of 2016 at a level one trauma center and its associated outpatient surgical center. Basic univariate statistical analyses were performed, and the two groups were compared for primary and secondary outcome measures.Results:The data showed no significant increase in intraoperative complication rateswhen operating on a standard hospital stretcher compared to operating on an OR table. There were a total of 6 postoperative complications in the stretcher group and a total of 11 complications in the OR table group. The most common postoperative complication seen in both cohorts was infection. There was one intraoperative complication in the OR table group and none in the stretcher group. With regard to total operating room time, surgical time, and delta time (overall OR room time minus surgical time which was used to calculate the turnover time), we found that the OR table group had shorter times in each category. The total OR time for the OR table group was a mean time of 105 minutes compared to 146 minutes seen in the stretcher group (p= 0.0002). Similarly, there was a shorter mean surgical time for surgeries done on an OR table (73 minutes) when compared to surgeries done on a stretcher (104 minutes) (p = 0.0026). Finally, the average turnover time (delta time) for the OR table group was 32 minutes while the average turnover time for the stretcher group was 42 minutes (p= 0.0002). The average tourniquet time for the OR table group was 36 minutes as compared to 41 in the stretcher group (p=0.467).Conclusion:Operating on a typical hospital stretcher is a safe alternative to operating on a standard operating room table as there was no increased complication rate seen with surgeries performed on a stretcher compared to an OR table.Level of Evidence: Level 3 evidence

Midline Craniotomy for Resection of Cavernous Malformation: 2-Dimensional Operative Video

This patient presented with a cavernous malformation in the inferior posterior third ventricle extending into the aqueduct. The patient was positioned supine on the operating room table with the head rotated into the horizontal plane. The choroidal fissure is opened lateral to the choroid plexus. This technique allows for the choroid plexus to serve as protection against forniceal manipulation. Rigid retraction was applied to the cerebral falx and corpus callosum to permit aqueductal visualization. The lighted instruments are paramount for adequate visualization of the third ventricle and during dissection of the lesion. Intraoperative visualization and postoperative imaging confirm gross total resection of the lesion. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute.

Improving the Odds

Precise localization of a rib lesion for its resection remains a challenge because of multiple factors including nonpalpable pathology, unfavorable body habitus, inaccurate clinical examination, and unreliable rib count on physical examination, unfavorable lesion location within a rib (its posterior aspect), and resection of sclerotic lesions with grossly intact rib cortex. We describe a novel rib localization technique that eliminates potential mistakes and avoids resection of an inappropriate rib. Our method of rib localization includes placement of metallic coils by interventional radiologists under computed tomography guidance where two coils are deployed within the intercostal spaces, one superior and one inferior to the rib lesion. Intraoperative use of fluoroscopy results in precise localization of rib lesions even in cases where the pathology is not grossly apparent. We implemented this approach in 2014 and have since performed it in five patients for both lytic and sclerotic lesions. Placement of markers superficial to the intercostal spaces resulted in their displacement in one case. Successfully, we removed the correct ribs in each patient without technical difficulties or complications. Our series demonstrates a novel strategy for a highly accurate and relatively easy way to identify the exact portion of the rib for surgical resection. Intercostal space positioning of the coil markers superior and inferior to the lesion prevents their dislodgement during patient transport and positioning on the operating room table, which improves rib identification accuracy and reliability. When combined with intraoperative fluoroscopy, it will greatly eliminate resection of incorrect ribs.