METHODS: This study was a retrospective multi-center comparative cohort study.
METHODS: A retrospective institutional database of operative adult spinal deformity patients was utilized. All fusions > 5 vertebral levels and including the sacrum/pelvis were eligible for inclusion. Revisions, 3 column osteotomies, and patients with < 2-year clinical follow-up were excluded. Patients were separated into 3 groups based on surgical approach: 1) posterior spinal fusion without interbody (PSF), 2) PSF with interbody (PSF-IB), and 3) anteroposterior (AP) fusion (anterior lumbar interbody fusion or lateral lumbar interbody fusion with posterior screw fixation). Intraoperative, radiographic, and clinical outcomes, as well as complications, were compared between groups with ANOVA and χ2 tests.
RESULTS: One-hundred and thirty-eight patients were included for study (PSF, n = 37; PSF-IB, n = 44; AP, n = 57). Intraoperatively, estimated blood loss was similar between groups (p = 0.171). However, the AP group had longer operative times (547.5 min) compared to PSF (385.1) and PSF-IB (370.7) (p < 0.001). Additionally, fusion length was shorter in PSF-IB (11.4) compared to AP (13.6) and PSF (12.9) (p = 0.004). There were no differences between the groups in terms of change in alignment from preoperative to 2 years postoperative. There were no differences in clinical outcomes. While postoperative complications were largely similar between groups, operative complications were higher in the AP group (31.6%) compared to the PSF (5.4%) and PSF-IB (9.1) groups (p < 0.001).
CONCLUSIONS: While there were differences in intraoperative outcomes (operative time and fusion length), there were no differences in postoperative clinical or radiographic outcomes. AP fusion was associated with a higher rate of operative complications.

Background/Objectives: Cholesteatoma presents significant management challenges in otolaryngology. This study aimed to delineate the influence of demographic and clinical characteristics, preoperative imaging, and surgical approaches on treatment success in cholesteatoma management. Methods: A cross-sectional analytical study was conducted at the Otolaryngology Department of the University Hospital from January 2021 to December 2022. It included 68 patients diagnosed with cholesteatoma, focusing on three objectives: assessing the impact of demographic and clinical characteristics on treatment outcomes, evaluating the predictive value of preoperative imaging findings, and analyzing the influence of surgical factors. Results: The study population predominantly consisted of male (56%) and Saudi (81%) patients, with an average age of 45 years. Logistic regression revealed that older age (OR: 1.05), male gender (OR: 0.63), and non-Saudi Arab ethnicity (OR: 2.14) significantly impacted treatment outcomes. Clinical characteristics such as severe disease severity (OR: 3.00) and longer symptom duration (OR: 0.96) also influenced treatment success. In preoperative imaging, labyrinthine fistula (Regression Coefficient: 0.63) and epidural extension (Coefficient: 0.55) emerged as key predictors. The surgical factors that significantly affected the outcomes included the extent of surgery (Complete Removal OR: 3.32) and the use of endoscopic approaches (OR: 1.42). Conclusions: This study highlights that patient demographics, clinical profiles, specific preoperative imaging features, and surgical strategies multifactorially determine cholesteatoma treatment success. These findings suggest the necessity for a tailored approach in cholesteatoma management, reinforcing the importance of individualized treatment plans based on comprehensive preoperative assessments.

BACKGROUND: The optimal proximal margin (PM) length for Siewert II/III adenocarcinoma of the esophagogastric junction (AEJ) remains unclear. This study aimed to determine the optimal PM length using an abdominal approach to guide surgical decision-making.
METHODS: A prospective study analyzed 304 consecutive patients diagnosed with Siewert II/III AEJ between January 2019 and December 2021. Total gastrectomy was performed via the abdominal approach, and PM length was measured on fixed gross specimens. X-Tile software determined the optimal PM cut-point based on progression-free survival (PFS). Univariate analyses compared baseline characteristics across PM groups, while survival analyses utilized Kaplan-Meier estimation and Cox proportional hazards regression for assessing the impact of margin length on survival. Multivariable analyses were conducted to adjust for confounding variables.
RESULTS: The study included 264 AEJ cases classified as Siewert II (71.97%) or III (28.03%). The median gross PM length was 1.0 cm (IQR: 0.5 cm-1.5 cm, range: 0 cm-6 cm). PM length ≥1.2 cm was associated with a lower risk of disease progression compared to PM length 0.4 cm on PFS (HR = 0.41, 95% CI 0.20-0.84, P = 0.015). Moreover, PM ≥ 1.2 cm improved prognosis in subgroups of T4 or N3, tumor size <4 cm, Siewert II, and Lauren classification.
CONCLUSIONS: For Siewert type II/III AEJ, a proximal margin length ≥1.2 cm (1.65 cm in situ) is associated with improved outcomes. These findings offer valuable insights into the association between PM length and outcomes in Siewert II/III AEJ, providing guidance for surgical approaches and aiding clinical decision-making to enhance patient outcomes.

Rapid-sequence tracheotomy and scalpel-bougie tracheotomy are two published approaches for establishing emergency front-of-neck access in infants. It is unknown whether there is a difference in performance times and success rates between the two approaches.
The aim of this cross-over randomized control trial study was to investigate whether the two approaches were equivalent for establishing tracheal access in rabbit cadavers. The underlying hypothesis was that the time to achieve the tracheal access is the same with both techniques.
Between May and September 2022, thirty physicians (pediatric anesthesiologists and intensivists) were randomized to perform front-of-neck access using one and then the other technique: rapid-sequence tracheotomy and scalpel-bougie tracheotomy. After watching training videos, each technique was practiced four times followed by a final tracheotomy during which study measurements were obtained. Based on existing data, an equivalence margin was set at ∆ = ±10 s for the duration of the procedure. The primary outcome was defined as the duration until tracheal tube placement was achieved successfully. Secondary outcomes included success rate, structural injuries, and subjective participant self-evaluation.
The median duration of the scalpel-bougie tracheotomy was 48 s (95% CI: 37-57), while the duration of the rapid-sequence tracheotomy was 59 s (95% CI: 49-66, p = .07). The difference in the median duration between the two approaches was 11 s (95% CI: -4.9 to 29). The overall success rate was 93.3% (95% CI: 83.8%-98.2%). The scalpel-bougie tracheotomy resulted in significantly fewer damaged tracheal rings and was preferred among participants.
The scalpel-bougie tracheotomy was slightly faster than the rapid-sequence tracheotomy and favored by participants, with fewer tracheal injuries. Therefore, we propose the scalpel-bougie tracheostomy as a rescue approach favoring the similarity to the adult approach for small children. The use of a comparable equipment kit for both children and adults facilitates standardization, performance, and logistics.
ClinicalTrials.gov identifier: NCT05499273.

BACKGROUND: Osteochondritis dissecans (OCD) of the humeral capitellum is an important cause of elbow disability in young athletes. Large and unstable lesions sometimes require joint reconstruction with osteochondral autograft. Several approaches have been described to expose the capitellum for the purpose of treating OCD. The posterior anconeus-splitting approach and the lateral approach with or without release of the lateral ligamentous complex are the most frequently used for this indication. The surface accessible by these approaches has not been widely studied. This study compared the extent of the articular surface of the capitellum that could be exposed with the Kocher approach (without ligament release) vs. the posterior anconeus-splitting approach. A secondary outcome was the measurement of any additional area that could be reached with lateral ulnar collateral ligament release (Wrightington approach).
METHODS: The 3 approaches were performed on 8 adult cadaveric elbows: first, the Kocher approach; then, the anconeus-splitting approach; and finally, the Wrightington approach. The visible articular surface was marked out after completion of each approach.
RESULTS: The mean articular surface of the capitellum was 708 mm2 (range, 573-830 mm2). The mean visible articular surface was 49% (range, 43%-60%) of the total surface with the Kocher approach, 74% (range, 61%-90%) with the posterior anconeus-splitting approach, and 93% (range, 91%-97%) with the Wrightington approach. Although the Kocher approach provided access to the anterior part of the capitellum, the anconeus-splitting approach showed adequate exposure to the posterior three-quarters of the articular surface and overlapped the most posterior part of the Kocher approach. A combination of the 2 lateral ulnar collateral ligament-preserving approaches allowed access to 100% of the joint surface.
CONCLUSIONS: Most OCD lesions are located in the posterior area of the capitellum and can therefore be reached with the anconeus-splitting approach. When OCD lesions are located anteriorly, the Kocher approach without ligament release is efficient. A combination of these 2 approaches enabled the entirety of the joint surface to be viewed.

UNASSIGNED: Siewert type II adenocarcinoma of the esophagogastric junction (Siewert II AEG) can be resected by the right thoracoabdominal surgical approach (RTA) or abdominal-transhiatal surgical approach (TH) under minimally invasive conditions. Although both surgical methods achieve complete tumor resection, there is a debate as to whether the former method is superior to or at least noninferior to the latter in terms of surgical safety. Currently, a small number of retrospective studies have compared the two surgical approaches, with inconclusive results. As such, a prospective multicenter randomized controlled trial is necessary to validate the value of RTA (Ivor-Lewis) compared to TH.
UNASSIGNED: The planned study is a prospective, multicenter, randomized clinical trial. Patients (n=212) with Siewert II AEG that could be resected by either of the above two surgical approaches will be included in this trial and randomized to the RTA group (n=106) or the TH group (n=106). The primary outcome will be 3-year disease-free survival (DFS). The secondary outcomes will include 5-year overall survival (OS), incidence of postoperative complications, postoperative mortality, local recurrence rate, number and location of removed lymph nodes, quality of life (QOL), surgical Apgar score, and duration of the operation. Follow-ups are scheduled every three months for the first 3 years after the surgery and every six months for the next 2 years.
UNASSIGNED: Among Siewert II AEG patients with resectable tumors, this is the first prospective, randomized clinical trial comparing the surgical safety of minimally invasive RTA and TH. RTA is hypothesized to provide better digestive tract reconstruction and dissection of mediastinal lymph nodes while maintaining a high quality of life and good postoperative outcome. Moreover, this trial will provide a high level of evidence for the choice of surgical procedures for Siewert II AEG.
UNASSIGNED: Chinese Ethics Committee of Registering Clinical Trials, identifier (ChiECRCT20210635); Clinical Trial.gov, identifier (NCT05356520).

OBJECTIVE: The aim of this study was to determine if uncemented acetabular polyethylene (PE) liner geometry, and lip size, influenced the risk of revision for instability or loosening.
METHODS: A total of 202,511 primary total hip arthroplasties (THAs) with uncemented acetabular components were identified from the National Joint Registry (NJR) dataset between 2003 and 2017. The effect of liner geometry on the risk of revision for instability or loosening was investigated using competing risk regression analyses adjusting for age, sex, American Society of Anesthesiologists grade, indication, side, institution type, surgeon grade, surgical approach, head size, and polyethylene crosslinking. Stratified analyses by surgical approach were performed, including pairwise comparisons of liner geometries.
RESULTS: The distribution of liner geometries were neutral (39.4%; 79,822), 10° (34.5%; 69,894), 15° (21.6%; 43,722), offset reorientating (2.8%; 5705), offset neutral (0.9%; 1,767), and 20° (0.8%; 1,601). There were 690 (0.34%) revisions for instability. Compared to neutral liners, the adjusted subhazard ratios of revision for instability were: 10°, 0.64 (p < 0.001); 15°, 0.48 (p < 0.001); and offset reorientating, 1.6 (p = 0.010). No association was found with other geometries. 10° and 15° liners had a time-dependent lower risk of revision for instability within the first 1.2 years. In posterior approaches, 10° and 15° liners had a lower risk of revision for instability, with no significant difference between them. The protective effect of lipped over neutral liners was not observed in laterally approached THAs. There were 604 (0.3%) revisions for loosening, but no association between liner geometry and revision for loosening was found.
CONCLUSIONS: This registry-based study confirms a lower risk of revision for instability in posterior approach THAs with 10° or 15° lipped liners compared to neutral liners, but no significant difference between these lip sizes. A higher revision risk is seen with offset reorientating liners. The benefit of lipped geometries against revision for instability was not seen in laterally approached THAs. Liner geometry does not seem to influence the risk of revision for loosening. Cite this article: Bone Joint J 2021;103-B(12):1774-1782.

OBJECTIVE: To determine if primary cemented acetabular component geometry (long posterior wall (LPW), hooded, or offset reorientating) influences the risk of revision total hip arthroplasty (THA) for instability or loosening.
METHODS: The National Joint Registry (NJR) dataset was analyzed for primary THAs performed between 2003 and 2017. A cohort of 224,874 cemented acetabular components were included. The effect of acetabular component geometry on the risk of revision for instability or for loosening was investigated using log-binomial regression adjusting for age, sex, American Society of Anesthesiologists grade, indication, side, institution type, operating surgeon grade, surgical approach, polyethylene crosslinking, and prosthetic head size. A competing risk survival analysis was performed with the competing risks being revision for other indications or death.
RESULTS: The distribution of acetabular component geometries was: LPW 81.2%; hooded 18.7%; and offset reorientating 0.1%. There were 3,313 (1.5%) revision THAs performed, of which 815 (0.4%) were for instability and 838 (0.4%) were for loosening. Compared to the LPW group, the adjusted subhazard ratio of revision for instability in the hooded group was 2.31 (p < 0.001) and 4.12 (p = 0.047) in the offset reorientating group. Likewise, the subhazard ratio of revision for loosening was 2.65 (p < 0.001) in the hooded group and 13.61 (p < 0.001) in the offset reorientating group. A time-varying subhazard ratio of revision for instability (hooded vs LPW) was found, being greatest within the first three months.
CONCLUSIONS: This registry-based study confirms a significantly higher risk of revision after cemented THA for instability and for loosening when a hooded or offset reorientating acetabular component is used, compared to a LPW component. Further research is required to clarify if certain patients benefit from the use of hooded or offset reorientating components, but we recommend caution when using such components in routine clinical practice. Cite this article: Bone Joint J 2021;103-B(11):1669-1677.

BACKGROUND: the right- and left-approach open esophagectomies remain the general procedures among patients with operable thoracic esophageal squamous cell carcinoma (ESCC). The choice between the two approaches for elderly patients is controversial.
METHODS: we performed a 1:1 propensity score matching (PSM) analysis to compare the impact of right- and left-approach esophagectomies on survival and perioperative complications of elderly ESCC patients. Patients aged over 70 receiving esophagectomy to treat the thoracic ESCC were retrospectively retrieved.
RESULTS: a total of 276 patients were included in the study. Among them, 75 (27.2%) patients received right-approach esophagectomy. After match, 114 patients (57 pairs) undertook right or left-approach esophagectomy displayed no difference among clinicopathological characteristics. Both the overall survival (54.6% vs. 32.6%, P=0.036) and disease-free survival (52.7% vs. 20.2%, P=0.021) were significant better in right-approach group, along with better lymph node resection, and lower incidence of recurrence. However, increased incidences of postoperative pneumonia (P=0.040), respiratory failure (P=0.028), and sub-clinical anastomotic leak (P=0.032) were found in right-approach group as well, although the perioperative mortality was similar between groups.
CONCLUSIONS: Right-approach esophagectomy should be accepted as a preferential surgical approach for elderly patients with ESCC.

Adequate exposure of the proximal humerus is necessary to address atypical or complex proximal humerus fractures and orthopedic tumors. Surgical management may be difficult through existing approaches due to their limited nature and the delicate neurovascular anatomy of the shoulder. The deltoid lift, a previously described extensile approach, can be incorporated into the surgeon\'s armamentarium as an alternative exposure to the proximal humerus. The objective of this study was to quantify and compare the humeral exposure achieved through the deltoid lift with the standard direct lateral deltoid-splitting, anterolateral acromial, and deltopectoral approaches in terms of surface area and exposure of key anatomic landmarks.
Each approach was performed a minimum of 8 times on 18 cadaveric specimens. After identifying landmarks, exposure area of exposed humerus was quantified using digital images and ImageJ software.
The deltoid lift yielded an average exposure area of 46 cm2. Comparison of the exposure area for the deltoid lift against each of the other approaches yielded statistical significance ( P < .01). The exposure provided was 2-folds greater than that of the next most extensive approach. All anatomic landmarks were directly visible through the deltoid lift as compared with the remaining approaches, through which only 1 landmark was directly visualized and only 2 of the 3 remaining were palpable through the approach.
The deltoid lift extensile surgical exposure to the proximal humerus provides the largest humeral exposure with the greatest visibility of landmarks relative to the 3 most widely utilized standard approaches.