The prevalence of gluteal tendinopathy (GT) associated with osteoarthritis of the hip is difficult to determine as it is frequently undiagnosed or misdiagnosed as trochanteric bursitis. Its relationship to total hip arthroplasty (THA) outcomes is currently unknown. The aim of this study was to determine the incidence of GT at the time of hip arthroplasty and examine the relationship between GT and patient reported outcomes (PROMS) before and after THA. Patients undergoing THA for primary osteoarthritis between August 2017 and August 2020 were recruited. Tendinopathy was assessed and graded at time of surgery. PROMS included the Oxford Hip Score (OHS), HOOS JR, EQ-5D, and were collected preoperatively and at one year after THA. Satisfaction with surgery was also assessed at 1 year. 797 patients met eligibility criteria and were graded as Grade 1: normal tendons (n =496, 62%), Grade 2: gluteal tendinopathy but no tear (n=222, 28%), Grade 3: partial/full thickness tears or bare trochanter (n=79, 10%). Patients with abnormal gluteal tendons were older (p=0.001), had a higher mean BMI (p=0.01), and were predominately female (p=0.001). Patients with higher grade tendinopathy had statistically significant inferior PROMS at one year, OHS score (44.1 v 42.9 v 41.3, p 0.001) HOOS JR (89.3 V 86.3 V 85.6 p 0.005). Increasing gluteal tendon grade was associated with a greater incidence of problems with mobility (p=0.001), usual activities (p=0.001) and pain (p=0.021) on EQ5D. There was a 3 times relative risk of overall dissatisfaction with THA in the presence of gluteal tears. This study demonstrated that gluteal tendinopathy was commonly observed and associated with inferior 1-year PROMS in patients undergoing THA for OA. Increasing degree of tendinopathy was a negative prognostic factor for worse functional outcomes and patient satisfaction

Total hip arthroplasty has become one of the most successful orthopaedic procedures with long-term survival rate. An ever-increasing acceptance of the potential longevity of THA systems has contributed to an increasing incidence of THA in younger and more active patients. Nowadays, especially in younger patients, cementless THA is the favored method worldwide. Since the first cementless THA in late 1970s, many implant designs and modifications have been made. Despite excellent long-term results for traditional straight cementless stems, periprosthetic fractures or gluteal insufficiency are still a concern. For instance, as reported in a meta-analysis by Masonis and Bourne, the incidence of gluteal insufficiency after THA varies between 4% and 22%. In contrast, the flattened lateral profile of the SP-CL. ®. anatomical cementless stem can protect the greater trochanter during the use of cancellous bone compressors and can avoid gluteal insufficiency after THA. Another benefit of this stem design is the rotational stability and the natural load transfer due to the anatomical concept. In this context, we report our experiences using the SP-CL. ®. anatomical cementless stem. The study group consists of 1452 THA cases (850 male, 602 female) with an average age of 62 years (range 25–76 years). After a mean follow-up of 20 months, in seven cases (0.5%) a stem exchange was necessitated. The reason for stem revision was periprosthetic fracture in 4 cases (0.3%) and periprosthetic joint infection in three cases (0.2%). In five patients, hip dislocation and in four patients migration of the stem occurred. However, stem exchange was not required in those cases. In conclusion, the SP-CL. ®. anatomical cementless stem has excellent short-term results

Introduction. At Sheffield Children's Hospital, treatment of leg length discrepancy is a common procedure. Historically, this has been done with external fixators. With the development in intramedullary technology, internal nails have become the preferred modality for long bone lengthening in the adolescent population. However, it is important to review whether this technology practically reduces the known challenges seen and if it brings any new issues. Therefore, the aim of this review is to retrospectively evaluate the therapeutic challenges of 16 fit-bone intramedullary femoral lengthening's at Sheffield Children's Hospital between 2021–2022. Materials & Methods. The international classification of function (ICF) framework was used to differentiate outcomes. The patient's therapy notes were retrospectively reviewed for themes around structural, activity and participation limitation. The findings were grouped for analysis and the main themes presented. Results. There were 8 males, mean age 17.4 years (range 17–18) and 8 females, mean age 15.9 years (range 14–18). 5 right and 11 left femurs were lengthened. Underlying pathology varied amongst the 16 patients. All patients went into a hinged knee brace post operatively. Structural limitations included: pain, fixed flexion deformity of the knee, loss of knee flexion, quadriceps muscle lag, muscle spasms and gluteal weakness. The primary activity limitation was reduced weight bearing with altered gait pattern. Participation limitations included reduced school attendance and involvement in activities with peers. Access to Physiotherapy from local services varied dramatically. Five of the cohort have completed treatment. Conclusions. Anecdotally, intramedullary femoral lengthening nails have perceived benefits for families compared to external fixators in the adolescent population. However, there remain musculoskeletal and psychosocial outcomes requiring therapeutic management throughout the lengthening process and beyond. Therefore, quantifying these outcomes is essential for measuring the impact on each patient for comparison. To interpret these themes, we need to evaluate the outcomes objectively, this was not done consistently in this review. Future research should look at outcome measures that are sensitive to all aspects of the ICF. With an aim of improving the therapeutic treatment provided and the overall outcome for the children treated

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

Introduction. Snapping hip syndrome is a common condition affecting 10% of the population. It is due to the advance of the iliotibial band (ITB) over the greater trochanter during lower limb movements and often associated with hip overuse, such as in athletic activities. Management is commonly conservative with physiotherapy or can be surgical to release the ITB. Here we carry out a systematic review into published surgical management and present a case report on an overlooked cause of paediatric snapping hip syndrome. Materials & Methods. A systematic review looking at published surgical management of snapping hip was performed according to PRISMA guidelines. PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Library databases were searched for “((Snapping hip OR Iliotibial band syndrome OR ITB syndrome) AND (Management OR treatment))”. Adult and paediatric published studies were included as few results were found on paediatric snapping hip alone. Results. 1548 studies were screened by 2 independent reviewers. 8 studies were included with a total of 134 cases, with an age range of 14–71 years. Surgical management ranged from arthroscopic, open or ultrasound guided release of the ITB, as well as gluteal muscle releases. Common outcome measures showed statistically significant improvement pre- and post-operatively in visual analogue pain score (VAPS) and the Harris Hip Score (HHS). VAPS improved from an average of 6.77 to 0.3 (t-test p value <0.0001) and the HHS improved from an average of 62.6 to 89.4 (t-test p value <0.0001). Conclusions. Although good surgical outcomes have been reported, no study has reported on the effect of rotational profile of the lower limbs and snapping hip syndrome. We present the case of a 13-year-old female with snapping hip syndrome and trochanteric pain. Ultrasound confirmed external snapping hip with normal soft tissue morphology and radiographs confirmed no structural abnormalities. Following extensive physiotherapy and little improvement, she presented again aged 17 with concurrent anterior knee pain, patella mal-tracking and an asymmetrical out-toeing gait. CT rotational profile showed 2° of femoral neck retroversion and excessive external tibial torsion of 52°. Consequently, during her gait cycle, in order to correct her increased foot progression angle, the hip has to internally rotate approximately 35–40°, putting the greater trochanter in an anterolateral position in stance phase. This causes the ITB to snap over her abnormally positioned greater trochanter. Therefore, to correct rotational limb alignment, a proximal tibial de-rotation osteotomy was performed with 25° internal rotation correction. Post-operatively the patient recovered well, HHS score improved from 52.5 to 93.75 and her snapping hip has resolved. This study highlights the importance of relevant assessment and investigation of lower limb rotational profile when exploring causes of external snapping hip, especially where ultrasound and radiographs show no significant pathology

The direct lateral (or anterolateral) approaches to the hip for revision THA involve detachment of the anterior aspect of the gluteus medius from the trochanter along with a contiguous sleeve of the vastus lateralis. Anterior retraction of this flap of gluteus medius and vastus lateralis and simultaneous posterior retraction of the femur creates an interval for division of gluteus minimus and deeper capsular tissues and exposure of the joint. To enhance reattachment of this flap of the anterior portion of the gluteus medius and vastus lateralis back to the trochanter, an oblique wafer of bone can be elevated along with the muscle off of the anterolateral portion of the trochanter. This bony wafer prevents suture pull out when large nonabsorbable sutures are used around or through the fragment and passed into the bone of the trochanteric bed for reattachment during closure. To prevent excessive splitting proximally into the gluteus medius muscle (and resulting damage to the superior gluteal nerve), it is often helpful to extend the muscle split further distally down into the vastus lateralis. This combined with careful elevation of the gluteal muscles off of the ilium (instead of splitting them) helps provide excellent and safe exposure of the entire rim of the acetabulum and access to the supracetabular region for bone grafting, acetabular augment placement and even fixation of the flanges of a cage. A simple method for posterior column plating via the anterolateral approach involves contouring of the distal end of the plate around the base of the ischium at the inferior edge of the socket. When an extended osteotomy of the femur is needed to correct deformity, remove a well-fixed implant or cement, the “extensile” variation of this same surgical approach involves a Wagner style (lateral to medial) osteotomy of the greater trochanter and proximal femur. The anterior portion of the femur after it is osteotomised is elevated as a separate segment while maintaining the soft tissue attachments to the bone as much as possible to aid osteotomy healing. After implant or cement removal, this approach gives excellent direct access to the distal femur for placement of a long stem revision femoral component without bone-implant conflict proximally because of the bow of the femur. The anterolateral approach (and extensile variants detailed above) can be used routinely and safely in the full range of revision THA procedures, or it can be employed selectively, if desired, in cases at increased risk for dislocation

Anterior surgical approaches for total hip arthroplasty (THA) have increased popularity due to expected faster recovery and less pain. However, the direct anterior approach (Heuter approach which has been popularised by Matta) has been associated with a higher rate of early revisions than other approaches due to femoral component loosening and fractures. It is also noted to have a long learning curve and other unique complications like anterior femoral cutaneous and femoral nerve injuries. Most surgeons performing this approach will require the use of an expensive special operating table. An alternative to the direct anterior approach is the anterior-based muscle-sparing approach. It is also known as the modified Watson-Jones approach, anterolateral muscle-sparing approach, minimally invasive anterolateral approach and the Röttinger approach. With this technique, the hip joint is approached through the muscle interval between the tensor fascia lata and the gluteal muscles, as opposed to the direct anterior approach which is between the sartorius and rectus femoris and the tensor fascia lata. This approach places the femoral nerve at less risk for injury. I perform this technique in the lateral decubitus position, but it can also be performed in the supine position. An inexpensive home-made laminated L-shaped board is clamped on end of table allowing the ipsilateral leg to extend, adduct, and externally rotate during the femoral preparation. This approach for THA has been reported to produce excellent results. One study reports a complication rate of 0.6% femoral fracture rate and 0.4% revision rate for femoral stem loosening. In a prospective randomised trial looking at the learning curve with new approach, the anterior-based muscle-sparing anterior approach had lower complications than a direct anterior approach. The complications and mean operative time with this approach are reported to be no different than a direct lateral approach. Since this surgical approach is not through an internervous interval, a concern is that this may result in a permanent functional defect as result of injury to the superior gluteal nerve. At a median follow-up of 9.3 months, a MRI study showed 42% of patients with this approach had fat replacement of the tensor fascia lata, which is thought to be irreversible. The clinical significance remains unclear, and inconsequential in my experience. A comparison MRI study showed that there was more damage and atrophy to the gluteus medius muscle with a direct lateral approach at 3 and 12 months. My anecdotal experience is that there is faster recovery and less early pain with this approach. A study of the first 57 patients I performed showed significantly less pain and faster recovery in the first six weeks in patients performed with the anterior-based muscle-sparing approach when compared to a matched cohort of THA patients performed with a direct lateral approach. From 2004 to 2017, I have performed 1308 total hip replacements with the anterior-based muscle sparing approach. Alternatively, I will use the direct lateral approach for patients with stiff hips with significant flexion and/or external rotation contractures where I anticipate difficulty with femoral exposure, osteoporotic femurs due to increased risk of intraoperative trochanteric fractures, previously operated hips with scarring or retained hardware, and Crowe III-IV dysplastic hips when there may be a need for a femoral shortening or derotational osteotomy. Complications have been very infrequent. This approach is a viable alternative to the direct anterior approach for patients desiring a fast recovery. The anterior-based muscle-sparing approach is the approach that I currently use for all outpatient total hip surgeries

Surgical biopsies are still considered the gold standard in obtaining tumor tissue samples. In this study, we will analyze the core needle biopsy in the evaluation of musculoskeletal tumors focusing on the accuracy, effectiveness, and safety of this technique in comparison to an open biopsy procedure. This is a retrospective case series at King Abdulaziz Medical City (KAMC). All medical records from all patients who had a core needle biopsy (CNB) for a musculoskeletal mass and eventually underwent excisional biopsy between January 2010 and December 2016 at KAMC were included. Besides patient demographic data, the data extracted included the locations of the suspected mass, type of tissue acquired (bone or soft tissue), number of biopsies, complications reported during the procedure, histopathological report of core needle biopsy. A total of 262 patients who were suspected to have a musculoskeletal tumor were identified. Female to male ratio was (1:1.4) and paediatrics (of 93.1%. The AUC of CNB in comparison to excisional biopsy was 0.86. The most common site of tumor extraction was in lower extremities (47.3%), followed by upper extremities (23.7%), pelvis and gluteal area (19.5%) and spine (9.5%). In conclusion, CNB is cost-effective, safe and minimally invasive in bony and soft tissue lesions in comparison to an open biopsy procedure. Therefore, initiatives are required to implement this procedure to the majority of health care centers

Hip abductor deficiency (HAD) associated with hip arthroplasty can be a chronic, painful condition that can lead to abnormalities in gait and instability of the hip. HAD is often confused with trochanteric bursitis and patients are often delayed in diagnosis after protracted courses of therapy and steroid injection. A high index of suspicion is subsequently warranted. Risk factors for HAD include female gender, older age, and surgical approach. The Hardinge approach is most commonly associated with HAD because of failure of repair at the time of index surgery or subsequent late degenerative or traumatic rupture. Injury to the superior gluteal nerve at exposure can also result in HAD and is more commonly associated with anterolateral approaches. Multiple surgeries, chronic infection, and chronic inflammation from osteolysis or metal debris are also risk factors especially as they can result in bone stock deficiency and direct injury to muscle. Increased offset and/or leg length can also contribute to HAD, especially when both are present. Physical exam demonstrates abductor weakness with walking and single leg stance. There is often a palpable defect over the greater trochanter and palpation in that area usually elicits significant focal pain. Note may be made of multiple incisions. Increased leg length may be seen. Radiographs may demonstrate avulsion of the greater trochanter or significant osteolysis. Significant polyethylene wear or a metal-on-metal implant should be considered as risk factors, as well as the presence of increased offset and/or leg length. Ultrasound or MRI are helpful in confirming the diagnosis but false negatives and positive results are possible. Treatment is difficult, especially since most patients have failed conservative management before diagnosis of HAD is made. Surgical options include allograft and mesh reconstruction as well as autologous muscle transfers. Modest to good results have been reported, but reproducibility is challenging. In the case of increased offset and leg length, revision of the components to reduce offset and leg length may be considered. In the case of significant instability, abductor repair may require constrained or multi-polar liners to augment the surgical repair. HAD is a chronic problem that is difficult to diagnose and treat. Detailed informed consent appropriately setting patient expectations with a comprehensive surgical plan is required if surgery is to be considered. Be judicious when offering this surgery

Traditional risk factors for post-operative neuropathy include learning curve of surgical approach, DDH, and significant leg lengthening (>1 inch). Despite these risk factors, the most common scenario of a neuropathy is in a routine THA, by an experienced surgeon, for osteoarthritis, with no leg lengthening. Post-operative hematoma can lead to nerve compression, albeit rarely. The usual clinical presentation is of an acute event, with a previously intact nerve, sometime within the first days of surgery. Once diagnosed, immediate surgical decompression should be performed. Sciatic neuropathy is the most common, regardless of surgical approach, but the posterior approach poses the highest risk. Routine gluteus maximus tendon release may help to reduce the risk. When seen in the PACU, our approach is to immediately perform CT imaging to evaluate nerve integrity or to check on acetabular screw position. If no underlying cause is identified, the patient will be managed conservatively with foot orthotics and monitored for recovery. Femoral nerve palsy (FNP) can result in significant initial disability. Fortunately most patients recover function (although it can take over 18 months). In the early post-operative period it is often diagnosed after a patient complains of the leg giving away while attempting to walk. A knee brace will assist the patient with mobilization while the nerve recovers. The highest incidence of FNP is described for the direct lateral approach. Superior gluteal nerve (SGN) palsy is related to the direct lateral approach and may be avoided if the gluteus medius split is made within the safe zone (<5 centimeters from the tip of the greater trochanter). While early post-operative limp is common after the direct lateral approach, the true reported incidence of SGN palsy is low. Few studies showed that the persistent positive Trendelenburg test and limp is not exclusively related to the SGN damage and therefore the clinical effect of the SGN damage remains controversial. Lateral femoral cutaneous nerve can be affected during the direct anterior hip approach. One study suggests the presence of peri-incisional numbness in over 80% of patients. This is akin to numbness seen lateral to the incision after TKA. The incidence of meralgia paresthetica is extremely low (<1%)

Revision hip approaches can be divided into posterior, anterior, transgluteal, and transtrochanteric. The approach chosen is dictated by what needs to be exposed and the approaches with which the surgeon is comfortable. The posterior approach remains posterior to the gluteus medius and protects the hip abductors. The disadvantage of a posterior approach is post-operative dislocation. The direct anterior approach is currently enjoying popularity as a primary technique. Surgeons experienced in the primary technique are applying it to revision surgery. The anterior approaches also protect the hip abductors. The disadvantage is poor access to the posterior acetabular column and mobilization of the femur to gain access to the femoral diaphysis. Transgluteal approaches split the gluteus medius typically keeping the anterior portion of the medius intact with the vastus lateralis. Proximal exposure is limited by the superior gluteal nerve, which is 4 cm above the tip of the trochanter. The disadvantage of the transgluteal approach is difficult access to the posterior acetabular column and occasional abductor weakness. The advantage of both the anterior and transgluteal approaches is a lower dislocation rate. All three approaches are acceptable for revisions that only require acetabular rim and proximal femoral exposure. More extensive exposure requires modifications to these approaches or the use of a transtrochanteric approach. Transtrochanteric approaches are defined by the length of the osteotomy (conventional or extended) and if the vastus lateralis remains attached to the trochanteric fragment (slide). Distally extended osteotomies improve access to the femur. Osteotomies without a distal attachment to the lateralis can be retracted proximally thus improving exposure of the ilium

My goal for every patient undergoing THA is to achieve a perfect result. At the very least this includes no pain at any time, normal range of motion, normal functionality and a minimal chance of a second operation. Both the Posterolateral Approach (PLA) and the Direct Anterior Approach (DAA) have the capability of achieving these important goals. However, when you dive deeper into the goal of a “perfect” THA, some differences between the approaches become apparent. These include less muscle damage, faster recovery, and no restrictions at any time with the DAA as opposed to the PLA. Also there is some evidence of better wound healing (Poehling) and less chance of thromboembolic disease with the DAA (Stryker). The PLA violates all posterior structures of the hip joint, and specifically also goes through the gluteus maximus muscle. Done properly, the DAA spares all the gluteal muscles, and all of the posterior muscles about the hip. Bergin, who demonstrated lower levels of creatine kinase using the DAA vs PLA, has provided evidence of lower muscle damage. Faster recovery patterns have been well documented after DAA (Christen, Taunton). Part of this may be related to not needing hip precautions after DAA, while PLA patients are restricted in certain activities and positions in the postoperative period, because of the violation of the posterior capsule. Not having any restrictions enhances patient confidence, and patients tend to do more activities sooner with less reluctance and a subsequent faster recovery. It is my belief that DAA problems (outside the learning curve) are related to the dependence upon special tables and fluoroscopy, as opposed to proper exposure, to perform a DAA. If you don't test hip stability in the OR, you will miss subtle impingement that can lead to postoperative dislocation. If you depend upon fluoroscopy to guide acetabular reaming (without proper exposure), you run the risk of over-reaming or asymmetric reaming with dire consequences. If you don't measure leg length directly, but rely on fluoroscopic measurements, you run the risk of inadvertent leg lengthening

Introduction. The purpose of this study was to experimentally evaluate impingement and dislocation of total hip replacements while performing dynamic movements under physiological-like conditions. Therefore, a hardware-in-the-loop setup has been developed, in which a physical hip prosthesis actuated by an industrial robot interacts with an in situ-like environment mimicked by a musculoskeletal multibody simulation-model of the lower extremity. Methods. The multibody model of the musculoskeletal system comprised rigid bone segments of the lower right extremity, which were mutually linked by ideal joints, and a trunk. All bone geometries were reconstructed from a computed tomography set preserving anatomical landmarks. Inertia properties were identified based on anthropometric data and by correlating bone density to Hounsfield units. Relevant muscles were modeled as Hill-type elements, passive forces due to capsular tissue have been neglected. Motion data were captured from a healthy subject performing dislocation-associated movements and were fed to the musculoskeletal multibody model. Subsequently, the robot moved and loaded a commercially available total hip prosthesis and closed the loop by feeding the physical contact information back to the simulation model. In this manner, a comprehensive parameter study analyzing the impact of implant position and design, joint loading, soft tissue damage and bone resection was implemented. Results. The parameter study revealed a generally high dislocation risk for the seating-to-rising with adduction scenarios. Improper implant positioning or design could be compensated by adjusting prosthesis components correspondingly. Gluteal insufficiency or lower joint loading did not result in higher impingement or dislocation risk. However, severe malfunction of the artificial joint was found for proximal bone resection. Discussion. Previous testing setups ignored the impact of active muscles or relied on simplified contact mechanics. Herein, total hip replacement stability has been investigated experimentally by using a hardware-in-the-loop simulation. Thereby, several influencing factors such as implant position and design as well as soft tissue insufficiency and imbalance could be systematically evaluated with the goal to enhance joint stability

Revision hip approaches can be divided into posterior, anterior, transgluteal, and transtrochanteric. The approach chosen is dictated by what needs to be exposed and the approaches with which the surgeon is comfortable. The posterior approach remains posterior to the gluteus medius and protects the hip abductors. The disadvantage of a posterior approach is post-operative dislocation. The direct anterior approach is currently enjoying popularity as a primary technique. Surgeons experienced in the primary technique are applying it to revision surgery. The anterior approaches also protect the hip abductors. The disadvantage is poor access to the posterior acetabular column and mobilisation of the femur to gain access to the femoral diaphysis. Transgluteal approaches split the gluteus medius typically keeping the anterior portion of the medius intact with the vastus lateralis. Proximal exposure is limited by the superior gluteal nerve, which is 4cm above the tip of the trochanter. The disadvantage of the transgluteal approach is difficult access to the posterior acetabular column and occasional abductor weakness. The advantage of both the anterior and transgluteal approaches is a lower dislocation rate. All three approaches are acceptable for revisions that only require acetabular rim and proximal femoral exposure. More extensive exposure requires modifications to these approaches or the use of a transtrochanteric approach. Transtrochanteric approaches are defined by the length of the osteotomy (conventional or extended) and if the vastus lateralis remains attached to the trochanteric fragment (slide). Distally extended osteotomies improve access to the femur. Osteotomies without a distal attachment to the lateralis can be retracted proximally thus improving exposure of the ileum

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. Every surgeon who performs primary hip arthroplasties will expound the particular virtues of his or her particular routine surgical approach. Usually this approach will be the one to which the surgeon was most widely exposed to during residency training. There is a strong drive from patients, industry, surgeon marketing campaigns, and the media to perform THA through smaller incisions with quicker recoveries. The perceived advantage of the anterior approach is the lack of disturbance of the soft tissues surrounding the hip joint, less pain, faster recovery with the potential for earlier return to work, shorter hospital stay and improved cosmetic results. The potential disadvantages include less visibility, longer operation time, nerve injuries, femoral fractures, malposition and a long learning curve for the surgeon (and his / her patients). The anterior approach was first performed in Paris, by Robert Judet in 1947. The advantages of the anterior approach for THA are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to THA and his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation, while the posterior rotators and capsule provide active and passive stability and account for immediate stability of the hip and a low risk of dislocation. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intraoperative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally by lengthening the skin incision downward along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. The choice of approach used to perform a primary THA remains controversial. The primary goals are pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach as most of the positive data is based on comparisons with the anterolateral approach. The proposed benefits of the anterior approach are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the anterior approach in THA

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. The direct anterior approach (DAA) for THA was first performed in Paris, by Robert Judet in 1947. This procedure has since been performed consistently by a small group of surgeons and has recently gained great popularity. Access to the hip can be safely performed with one or two assistants. The advantages of the anterior approach for hip arthroplasty are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. Care must be taken to avoid cutting the lateral femoral cutaneous nerve which runs over the fascia of the sartorius. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to hip arthroplasty and by abandoning the posterior approach and adopting the anterior approach his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation while the posterior rotators and capsule provides active and passive stability and accounts for immediate stability of the hip and a low risk of dislocation. Using the anterior approach, patients are allowed to mobilise their hip freely. The gluteus maximus and tensor fascia latae muscles insert on the iliotibial band which joins them and form a ´hip deltoid´. Lack of disturbance of these abductors and pelvic stabilisers is another benefit of the anterior approach and accelerates gait recovery. The lateral femoral cutaneous nerve is at risk when the fascia is incised between the tensor fascia latae and the sartorius muscle. Damaging it may lead to a diminished sensation on the lateral aspect of the thigh and formation of a neuroma. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intra-operative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. In obese or muscular patients, where visibility is in doubt, an increase of the incision length will give the surgeon the required view. The choice of approach used to perform a primary THA remains controversial. The primary goal of a hip replacement is pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach. The proposed benefits of with the DAA are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the DAA in THA

Introduction. The possibility of corrosion at the taper junction of hip replacements was initially identified as a concern of generating adverse reactions in the late 1980s. Common clinical findings of failure are pain, clicking, swelling, fluid collections, soft tissue masses, and gluteal muscle necrosis identified intra operatively. Methodology. The joint replacement surgery was performed utilizing a posterior approach to the hip joint. The data from all surgical, clinical and radiological examinations was prospectively collected and stored in a database. Patients were separated into two groups based on bearing material, where group 1 had a CoC bearing and ABG modular stem whilst group 2 had a MoM bearing and SROM stem, with each group having 13 cases. Pre-operative revision surgery and post-operative blood serum metal ion levels we collected. Cup inclination and anteversion was measured using the Ein-Bild-Roentgen-Analyse (EBRA) software. A range of 2–5 tissue sections was examined per case. 2 independent observers that were blinded to the clinical patient findings scored all cases. The tissue grading for the H&E tissue sections were graded based on the presence of fibrin exudates, necrosis, inflammatory cells, metallic deposits, and corrosion products. The corrosion products were identified into 3 groups based on visible observation and graded based on abundance. A scanning electron microscope (SEM) Hitachi S3400 was used to allow for topographic and compositional surface imaging. Unstained tissue sections were used for imaging and elemental analysis. X-Ray diffraction was the analytical technique used for the taper debris that provided identification on the atomic and molecular structure of a crystal. Result. Group 1 patients showed a significant reduction (p = 0.0002) in the Co, however the decrease of Cr ion concentration had no statistical significance (p = 0.48). The Co (p = 0.001) and Cr (p = 0.02) levels significantly reduced after revision surgery for patients within group 2. The largest differences in the abundance between the two groups were for the brown/red corrosion particles where group 2 is highly significant (p<0.001) compared to group 1. The specific identification was determined using a mapping technique that showed the red/brown colour consisted of evenly scattered Ti (green) and Cr (red) particles (figure 1). Elemental analysis of the green shards showed chromium as a major metallic element with traces of cobalt (figure 2). The ABG modular collected debris matched the peaks of the following crystaline strucutes: chromium oxide (CrO), titantium oxide (TiO2), and chromium oxide (Cr2O3), and iron titanium oxide (Fe2Ti3O9) (figure 2). The peaks from the XRD scan were assessed against these possible elements which showed the most were aluminium nitride and chromium oxide (Cr2O3). Both implant configurations produced an ALTR response indicative from the tissue sections graded and visually observed. Conclusion. This study has characterized the corrosion products produced at taper junctions. The histology presented with similar results across the two groups suggestive that due to the same corrosion products found between both groups this was expected

To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock. Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively. Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14-70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator. The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6-50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population. This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience. Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present

Massive proximal femoral bone loss can be a complex problem, despite various modern technical and implant solutions. Due to inadequate bone stock and missing proximal fixation possibilities, including larger segmental osseous defects, the use of a mega prosthesis might become necessary. Coverage of the segmental bone loss in combination with distal fixation, can be achieved in either cemented or non-cemented techniques. Some implant types allow for additional fixation of the gluteal muscles, attached with non-absorbable sutures or synthetic mesh grafts. Although first reports about partial or even complete femoral replacement are available since the 1960's, larger case series or technical reports are rare within the literature and limited to some specialised centers. Most series are reported by oncologic centers, with necessary larger osseous resections of the femur. The final implantation of any mega prosthesis system requires meticulous planning, especially to calculate the appropriate leg length of the implant and resulting leg length. Combination of a posterior hip with a lateral knee approach allows for the enlargement to a total femur replacement, if necessary. The lateral vastus muscle is detached and the entire soft tissues envelope can be displaced medially. After implant and cement removal, non-structural bone might be resected. Trial insertion is important, due to the variation of overall muscle tension intraoperatively and prevention of early or late dislocation. Currently the use of proximal modular systems, including length, offset and anteversion adaption, became the technique of choice for these implant systems. However, just very few companies offer yet such a complete system, which might also be expanded to a total femur solution. We were able to evaluate our Endo-Klinik results of total-femur replacements within 100 consecutive patients in non-infected cases, after a mean follow up time of five years. There we “only” 68% patients without complications, main complications included: 13% revealed a deep infection; dislocation was found in 6%, material failure and consequent breakage in 3%, persistent patellar problems in 2% and finally 1% with peroneal nerve palsy. These results show that a total-femur replacement is associated with a high complication rate, even in non-infected patient cohorts

Twenty-two patients with piriformis syndrome underwent surgery between October 1995 and February 2002. The mean age was 56 years (range 28-90). Only 2 patients (9%) gave a history of trauma to the ipsilateral buttock. All the patients complained of deep buttock pain, which radiated to the ankle in 14 (63%), the calf in 4 (18%) and the thigh in 3 patients (13.6%). The symptoms were chronic, with a mean of 70 months (range 12-192) and patients had been previously seen by a mean of 2.6 specialists (range 1-6). There was associated neurosensory loss in 11 patients (50%). The symptoms were exacerbated by passive stretching and active contraction of the piriformis muscle. MRI of the lumbar spine (every case) and gluteal region (8 cases) were negative, while NCV tests (20 cases) were positive in 11 patients (55%). Previous conservative measures such as physiotherapy (59%) and epidural (40%) had failed. Every patient had surgical division of the piriformis tendon at the greater trochanter by the senior author. Abnormal anatomy was identified in 6 cases (29%). At 6 weeks (n=22), the symptoms had resolved in 6 patients (27%), were better in 8 (36%), no different in 7 (32%) and worse in 1 (4.5%). After a mean follow-up of 52 months (range 11-86), seven (35%) of patients were cured, 3 (15%) were better, 8 (40%) were no different, 2 (10%) were worse than pre-operatively and 2 had died of unrelated causes. Seventy-five percent of patients said that with hindsight they would undergo surgery again. One patient suffered a post-operative below knee DVT requiring no treatment. Surgery for piriformis syndrome in this selected group of patients led to an improvement or resolution of chronic symptoms in 64% of patients at 6 weeks, and 50% of patients after a mean follow-up of 52 months with minimal associated morbidity