Sciatic nerve injury remains a significant and devastating complication of total hip arthroplasty. Incidence as quoted in the literature ranges from 0.08% in primary joint replacement to 7.5% in revision arthroplasty. While as urgent exploration is recommended for nerve palsies associated with pain, management of sciatic nerve palsy with little or no pain is still controversial. In light of this, many patients with persistent palsies are often not referred to our specialist centre until after 6 months post-injury. The aim of this study was to review the outcomes of surgical intervention in patients presenting with sciatic nerve palsy more than 6 months after total hip arthroplasty. This retrospective cohort study identified 35 patients who underwent exploration and neurolysis of the affected sciatic nerve. All patients had documented follow-up at 1, 3, 6, 12 and 18 months to assess sensory and motor recovery. Patients were scored for sensory and motor function in the tibia and common personal nerve divisions, pre and post-operatively. The scoring system devised by Kline et al (1995) was used. Pre-operative electrophysiology was also reviewed. We found a statistically significant functional recovery following neurolysis of the sciatic nerve (p<0.01). A statistically significant relationship was also found between time to neurolysis and recovery of tibial nerve function (p = 0.02), such that greater delay to neurolysis was associated with poorer recovery. There was no significant relationship between time to neurolysis and recovery of common peroneal nerve function (p = 0.28). Our results indicate that the neurolysis of the sciatic nerve, six months or more post injury is associated with functional recovery. We feel that without surgical exploration this clinical improvement would not have occurred. Therefore, we believe that neurolysis plays a vital role at any stage of sciatic nerve injury. However, early presentation to a specialist unit is associated with better outcomes

Intro. Sciatic nerve injury (SNI) is a rare and potentially devastating complication after total hip arthroplasty (THA). Neural monitoring has been found in several studies to be useful in preventing SNI, but can be difficult to practically implement during surgery. In this study, we examine the results of using a handheld nerve stimulator for intraoperative sciatic nerve monitoring during complex THA requiring limb lengthening and/or significant manipulation of the sciatic nerve. Methods. We retrospectively reviewed a consecutive series of 11 cases (9 patients, 11 hips) with either severe developmental dysplasia of the hip (Crowe 3–4) or other underlying conditions requiring complex hip reconstruction involving significant leg lengthening and/or nerve manipulation. Sciatic nerve function was monitored intra-operatively with a handheld nerve stimulator by obtaining pre- and post-reduction conduction thresholds during component trialling. The results of nerve stimulation were then used to influence intraoperative decision- making (downsizing components, shortening osteotomy). Results. No permanent postoperative sciatic nerve complication occurred, with an average increase of 28.5mm in limb length, ranging from 6 to 51mm. In 2 out of 11 cases, a change in nerve response was identified after trial reduction, which resulted in an alternate surgical plan (femoral shortening osteotomy and downsizing femoral head). In the remainder cases, the stimulator demonstrated a response consistent with the baseline assessment, assuring that the appropriate lengthening was achieved without SNI. One patient had a transient motor and sensory peroneal nerve palsy, which resolved within two weeks. Conclusions. The intraoperative use of a handheld nerve stimulator facilitates surgical decision-making and can potentially prevent SNI. The real-time assessment of nerve function allows immediate corrective action to be taken before nerve injury occurs

We present simple but effective retractors used in pairs to expose the sciatic notch during Salter innominate osteotomy. We have found them to be useful for a wide range of procedures requiring similar exposure. We present them here in tribute to the memory of the designer Mercer Rang

Injury to the sciatic nerve is one of the more serious complications of acetabular fracture and traumatic dislocation of the hip, both in the short and long term. We have reviewed prospectively patients, treated in our unit, for acetabular fractures who had concomitant injury to the sciatic nerve, with the aim of predicting the functional outcome after these injuries. Of 136 patients who underwent stabilisation of acetabular fractures, there were 27 (19.9%) with neurological injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot and four had burning pain and altered sensation over the dorsum of the foot. Serial electromyography (EMG) studies were performed and the degree of functional recovery was monitored using the grading system of the Medical Research Council. In nine patients with a foot-drop, there was evidence of a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, the double-crush syndrome. At the final follow-up, clinical examination and EMG studies showed full recovery in five of the ten patients with initial muscle weakness, and complete resolution in all four patients with sensory symptoms (burning pain and hyperaesthesia). There was improvement of functional capacity (motor and sensory) in two patients who presented initially with complete foot-drop. In the remaining 11 with foot-drop at presentation, including all nine with the double-crush lesion, there was no improvement in function at a mean follow-up of 4.3 years

Introduction. Fast track arthroplasty regimens require preservation of motor power to perform early rehabilitation and ensure early discharge (1). Commonly performed nerve blocks like femoral and Sciatic nerve blocks results in motor weakness thereby interfering with early rehabilitation and may also predispose to patient falls (2, 3). Hence, targeting the terminal branches of the femoral and sciatic nerves around the knee joint under ultrasound is an attractive strategy. The nerve supply of interest for knee analgesia are the terminal branches of the femoral nerve, the genicular branches of the lateral cutaneous nerve of thigh, obturator and sciatic nerves (4). Methods. We modified the performance of the adductor canal block and combined it with US guided posterior pericapsular injection and lateral femoral cutaneous nerve block to provide analgesia around the knee joint. The femoral artery is first traced under the sartorius muscle until the origin of descending geniculate artery and the block is performed proximal to its origin. A needle is inserted in-plane between the Sartorius and rectus femoris above the fascia lata and 5 ml of 0.5% ropivacaine (LA) is injected to block the intermediate cutaneous nerve of thigh. The needle is then redirected to enter the fascia of Sartorius to deliver an additional 5ml of LA to cover the medial cutaneous nerve of thigh following which it is further advanced till the needle tip is seen to lie adjacent to the femoral artery under the Sartorius to perform the adductor canal block with an additional 15–20 ml of LA to cover nerve to vastus medialis, saphenous nerve and posterior division of the obturator nerve (Fig 1). The lateral cutaneous nerve of thigh is optionally blocked with 10 ml of LA near the anterior superior iliac spine between the origin of Sartorius and tensor fascia lata (Fig 2). The terminal branches of sciatic nerve to the knee joint is blocked by depositing 25 ml of local anesthetic solution between the popliteal artery and femur bone at the level of femoral epicondyles (Fig 3). Results. The initial experience of the block performed on 10 patients reveal the median (IQR) block duration is noted to be around 20 (±6.5) hours. The median (IQR) pain scores in the first 24 postoperative hours ranged from 0 (±0.5) to 3 (±2.5) at rest and 1.5 (±3.5) to 5.5 (±1) on movement. All patients were successfully mobilized on the morning of the first postoperative day. Conclusion. Motor sparing from the blocks while providing adequate analgesia can be achieved by selectively targeting the sensory innervation of the knee joint. Future comparative studies are needed to evaluate the performance of the block against other modes of analgesia for knee arthroplasty

(Case) 79-year-old woman. Past history, in 1989, right femur valgus osteotomy. in 1991, THA at left side. Follow-up thereafter. Hyaluronic acid injection for both knee osteoarthritis. (Clinical course)Her right hip pain getting worse and crawling indoors from the beginning of July 2013. We did right hybrid THA at August 2013(posterior approach, TridentHA cup, Exeter stem, Biolox Forte femoral head 28mm). But immediately, she dislocated twice than the third day after surgery because she became a delirium. It has been left by nurse for about 6 hours because of the midnight after the second dislocation. Next morning, check the dislocation limb position, closed reduction wasdone under intravenous anesthesia. As a result of waking up from the anesthesia, and complained of paralysis and violent pain in the right leg backward. A right lower extremity nerve findings, there is pain in the lower leg after surface about the calf, there was no apparent perception analgesia. Toe movement is weak, but the G-toe planter anddorsiflexion possible about M2, and neurological symptoms to relieved by flexion(above 70 degrees) of the right hip joint. Therefore, we thought that she suffered anterior dislocation of the sciatic nerve by the stem neck (retraction), judged to closed reduction was impossible, open reduction surgery was performed after waitingat hip flex position. But paralysis is gradually worsened during waiting surgery, toes movement had become impossible to operating room admission. Sciatic nerve is caught in front of the stem neck as expected, operative findings were able to finally reduction after removing the femoral head after dislocation. Anteversion of the cup was changed to 25 degrees from 15 degrees, and changed to 32mm diameter metal head and polyethylene liner. And we needed Intensive Care Unit(ICU) management after surgery for prevent recurrence of dislocation. Fitted with a hip brace for her, has not been re-dislocation. The sciatic nerve palsy improved in three months after the operation, the patient became able to walk without a cane. (Summary) We experienced a rare case suffered anterior dislocation of the sciatic nerve by the stem neck, and she had a good result after open reduction surgery

Most acetabular defects can be treated with a cementless acetabular cup and screw fixation. However, larger defects with segmental bone loss and discontinuity often require reconstruction with augments, a cup-cage, or triflange component – which is a custom-made implant that has iliac, ischial, and pubic flanges to fit the outer table of the pelvis. The iliac flange fits on the ilium extending above the acetabulum. The ischial and pubic flanges are smaller than the iliac flange and usually permit screw fixation into the ischium and pubis. The custom triflange is designed based on a pre-operative CT scan of the pelvis with metal artifact reduction, which is used to generate a three-dimensional image of the pelvis and triflange component. The design of the triflange involves both the manufacturing engineer and surgeon to determine the most appropriate overall implant shape, screw fixation pattern, and cup location and orientation. A plastic model of the pelvis, and triflange implant can be made in addition to the triflange component to be implanted, in order to assist the surgeon during planning and placement of the final implant in the operating room. A wide surgical exposure is needed including identification of the sciatic nerve. Proximal dissection of the abductors above the sciatic notch to position the iliac flange can risk denervation of the abductor mechanism. Blood loss during this procedure can be excessive. Implant survivorship of 88 to 100% at 53-month follow-up has been reported. However, in a series of 19 patients with Paprosky type 3 defects, only 65% were considered successful. The custom triflange also tends to lateralise the hip center which may adversely affect hip mechanics. The use of a triflange component is indicated in cases with massive bone loss or discontinuity in which other reconstructive options are not considered suitable

Introduction. Many determinants of the length of stay (LOS) for primary total knee arthroplasty (TKA) have been described. Multimodal, pre-emptive analgesia, age, walking aid score and stair score are some of them. Single shot peripheral nerve block is a popular method to provide prolonged analgesia in immediate post operative period after TKA. Delayed recovery from the nerve block can delay the rehabilitation programme and subsequently lengthen the LOS when the multi disciplinary team discharge criteria are well defined and standardized. The aim of this study is to calculate the incidence of delayed recovery from the sciatic and femoral nerve block administered in cases of primary TKA and its influence on LOS. Methods. All the patients undergoing primary TKA and receiving forty milliliters of 0.375% of Bupivacaine for sciatic and femoral nerve block since April 2010 till January 2011 have been included in the study. Patients demographics, date and day of operation, time of nerve block, complete recovery from the nerve block post operatively and date of discharge were recorded prospectively. Results. Total 34 patients were included in the study. 24 patients recovered from the effect of peripheral nerve block on the post operative day one and 10 patients recovered on the post operative day two. Mean LOS of patients recovered on post operative day one is 4.8 days and mean LOS of those who recovered on post operative day 2 is 5.6 days. Conclusion. Almost one third of the patients receiving forty milliliters of 0.375% of Bupivacaine for sciatic and femoral nerve block recovered late. Delayed recovery from nerve block seems to increase the duration to achieve the discharge criteria after primary TKA. This information can be used favorably to influence the outcome by altering the concentration and amount of anaesthetic agent used

High complication rates and poor outcomes have been widely reported in patients undergoing revision of large head metal-on-metal arthroplasty. A previous study from our centre showed high rates of dislocation, nerve injury, early cup loosening and pseudotumor recurrence. After noting these issues, we implemented the following changes in surgical protocol in all large head MOM revisions: One: Use of highly porous shells in all cases. Two: Use of largest femoral head possible. Three: Low threshold for use of dual mobility and constrained liners when abductors affected or absent posterior capsule. Four: Use of ceramic head with titanium sleeve in all cases. Five: Partial resection of pseudotumor adjacent to sciatic and femoral nerves. The purpose of the present study is to compare the new surgical protocol above to our previously reported early complications in this group of patients. We specifically looked at (1) complications including reoperations, (2) radiologic outcomes, and (3) functional outcomes. Complication rates after (Group 1), and before (Group 2) modified surgical protocol were compared using Chi-square test, assuming statistical significance p < 0 .05. Major complications occurred in 4 (8.3%) of 48 patients who had modified surgical technique, compared to 12 (38%) of 32 revisions prior to modification (p < 0 .05). Two hips of 48 (4.17%) endured dislocations in Group 1, compared to 9 of 32 (28%) in Group 2 (p < 0 .05). Four patients of 48 had repeat revision in Group 1: 2 for recurrence of pseudotumor, 1 for dislocation, and 1 for infection, compared to 6 patients who had 7 repeat revisions of 32 patients in Group 2: 3 for acetabular loosening, 3 for dislocation, and 1 for recurrence of pseudotumor (p=0.1). None of 48 revisions in Group 1 had acetabular loosening, compared to 4 of 32 in Group 2 (p=0.02). Two patients had nerve injury in Group 2, compared to none in Group 1 (p=0.16). The mean WOMAC pain score was 87.1 of 100 and the function score was 88.4 of 100 in Group 1, compared to a mean WOMAC pain score of 78 of 100 (p=0.6) and a function score of 83 of 100 in Group 2 (p=0.8). Modification of the surgical techniques described in the introduction has resulted in a significant decrease in complications in revision of large head MOM total hips. We continue to use this protocol and recommend it for these difficult cases

The surgical approach that is adequate for a primary total hip replacement may need to be modified to achieve a more extensile exposure as required for the revision procedure. A straightforward revision total hip replacement procedure can become quite complex when implant removal is attempted without adequate skill, instrumentation, or exposure. The most commonly used approaches in total hip replacement revision surgery are the transtrochanteric, posterolateral, and anterolateral. Although the effects of these approaches on the long-term clinical survival of the prosthetic composite are not completely clear, surgical approach does affect dislocation rates, trochanteric nonunion rates, and other indicators of clinical success. Transtrochanteric Approach - Three variations of the transtrochanteric approach exist: A) The classic Charnley trochanteric approach was popularised by virtue of its use in primary total hip arthroplasty (THA) and, therefore, was easily applied to revision THA. This approach allows excellent visualization of the lateral shaft of the femur, thus enhancing implant and cement removal. However, the classic Charnley approach is associated with a high incidence of trochanteric nonunion. Reattachment of the atrophied trochanteric fragment often requires adjunct fixation such as cables, hooks, or bolts. These devices can subsequently break, migrate, or generate particulate debris which, in turn, is capable of producing extensive granuloma. B) The trochanteric slide is accomplished by an anteromedial inclination of the osteotomy, thus providing a more stable interface for reattachment. The trochanteric slide offers the advantage of maintaining muscle continuity. The disadvantage of this technique is decreased visualization of the acetabulum. Adjunct fixation of the trochanter is also required with this approach. C) By creating a 6 cm to 12 cm distal extension to the trochanteric fragment, a large lateral window is developed which enhances both prosthesis and cement removal. Subsequently, trochanteric fixation is enhanced because the extended fragment increases the surface area available for fixation. Because the extended trochanteric osteotomy requires a larger bone resection, proximal femoral bone stock can be compromised. As a result, proximal prosthetic support with a tapered device can force the trochanteric fragment laterally, increasing the likelihood of nonunion. When an extended trochanteric osteotomy is used, the patient's postoperative physical therapy and rehabilitation course should be modified to protect the healing trochanteric fragment. Posterolateral Surgical Approach is used commonly in revision THA. The technique is popular because it is used widely for endoprosthetic replacement in the treatment of subcapital fractures. Also, the posterolateral approach is quite popular for primary THA. This approach has the advantage of maintaining the integrity of the abductor mechanism. Although femoral exposure is adequate, acetabular exposure can be limited. Also, this approach is associated with an increased incidence of dislocation. Another concern is its close proximity to the sciatic nerve, thus predisposing the patient to the risk of nerve injury. Anterolateral Surgical Approach has the advantage of improved visualization of the acetabulum and femur without the attending trochanteric complications and proximity to the sciatic nerve. This approach is associated with a low incidence of dislocation. However, the abductor muscle is divided or split and, therefore, abductor dysfunction can occur post-operatively. There also can be an increased incidence of heterotopic ossification, but it avoids the problem of trochanteric nonunion

Chronic postoperative pain (CPP) can occur in elective mid/hindfoot and ankle surgery patients. Multimodal pain management has been reported to reduce postoperative pain and opioid use, which may prevent the development of CPP. However, few studies have examined the impact of multimodal pain management strategies on CPP following complex elective mid/hindfoot and ankle surgery. The purpose of this study was to 1) evaluate current pain management strategies and 2) determine current definitions, incidence, and prevalence of CPP after elective mid/hindfoot and ankle surgery. Three databases (MEDLINE, Embase and Cochrane Library) were manually and electronically searched for English language studies published between 1990 and July 2017. For the first aim, we included comparative studies of adults undergoing elective mid/hindfoot and ankle surgery that investigated pre-, peri- or postoperative pain management. For the second aim, we included observational studies examining CPP definition, incidence, and prevalence. Two reviewers independently screened titles and abstracts, followed by full texts. Conflicts were resolved through discussion with a third reviewer. Reviewers also independently assessed the quality of studies meeting inclusion criteria using the Joanna Briggs Institute Critical Appraisal Checklist. For the first aim, 1159 studies were identified by the primary search, and seven high quality randomized controlled trials were included. Ankle arthroplasty or fusion and calcaneal osteotomy were the most common procedures performed. The heterogeneity of study interventions, though all regional anesthesia techniques, precluded meta-analysis. Most investigated continuous popliteal, sciatic and/or femoral nerve blockade. Participants were typically followed up to 48 hours postoperatively to examine postoperative pain levels and morphine consumption in hospital. Interventions effective at reducing postoperative pain and/or morphine consumption included inserting popliteal catheters using ultrasound instead of nerve stimulation guidance, perineural dexamethasone, and adding continuous femoral blockade to continuous popliteal blockade. Using more than one analgesic was generally more effective than using a single agent. Only two studies examined longer term pain management. One found no difference in pain levels and opioid consumption at two weeks with perineural or systemic dexamethasone use. The other found that pain with activity was significantly reduced at six months postoperatively with the addition of a femoral catheter infusion to a popliteal catheter infusion. For the second aim, only two studies of the 747 identified were selected. One prospective observational study defined CPP as moderate-to-severe pain at one year after foot and ankle surgery, and reported 21% and 43% of patients as meeting their definition at rest and with activity, respectively. The other study was a systematic review that reported 23–60% of patients experienced residual pain after total ankle arthroplasty. There is no standardized definition of CPP in this population, and incidence and prevalence are rarely reported and vary largely based on definition. Although regional anesthesia may be effective at reducing in-hospital pain and opioid consumption, evidence is very limited regarding longer-term pain management and associated outcomes following elective mid/hindfoot and ankle surgery

Introduction:. The lateral radiographs are useful in evaluation of the acetabular cup anteversion. However, this method was affected by variations in pelvic position and radiographic technique. In this study, we employed the ischial axis (IA) as an anatomical landmark on the lateral radiographs, and we investigated a relationship between IA and the anterior pelvic plane (APP) using three-dimensional computed tomography (3D-CT). Using these findings, we report a new method for accurate measurement of the acetabular cup anteversion on plain lateral radiographs using IA as an anatomical reference. Materials and Methods:. At first, preoperative3D-CT images were obtained in 109 patients who underwent total hip arthroplasty. The diagnosis was osteoarthritis in all patients. The angle between the IA (defined by a line connecting the anterior edge of the greater sciatic notch and the lesser sciatic notch) and APP (defined by the bilateral anterosuperior iliac spine and the symphysis) was measured on 3D-CT (Fig. 1). Secondly, postoperative lateral radiographs were obtained at 2 weeks, 4 weeks, 12 weeks, 24 weeks, and 52 weeks after surgery in 15 patients. The angle between a line tangential to the opening of the cup and a line perpendicular to APP was measured (Fig. 2). Three methods of acetebular cup position assessment were compared: 1) the present method, 2) Woo and Morrey method, and 3) software (2D template, Kyocera) method. Results:. The mean angle between IA and APP was 18.0 ± 3.5°. The mean acetabular cup anteversion measured using present method was 21.3°, Woo and Morrey method was 26.6°, and software method was 21.2°. The mean SDs of present method was 0.64°, Woo and Morrey method was 1.17°, and software method was 0.46°. Conclusions:. APP, considered as vertical in weight bearing, has a relatively consistent relationship between IA. The findings of this study provide a more consistent measurement of acetabular cup by reducing variation due to pelvic position

Fracture of the acetabulum can result in damage to the articular surface that ranges from minimal to catastrophic. Hip arthroplasty may be required for more severe injuries due to marked articular surface damage, post traumatic degenerative changes, persistent malunion or nonunion, or occasionally avascular necrosis and destruction of the femoral head. These problems may be seen following both closed and open fracture treatment, but prior open reduction and internal fixation often makes subsequent THA more difficult due to soft tissue scarring and retained hardware. In select acute acetabular fracture cases with severe initial comminution of the joint, open reduction and fixation can be technically impossible or so clearly destined to early failure that initial fracture treatment with combined limited fixation and simultaneous THA is the best option, especially in osteoporotic elderly fracture patients. Problems which may be encountered during any THA in a patient with a prior acetabular fracture include: difficult exposure due to soft tissue defects and scarring, presence of heterotopic ossification, and nerve palsy from the original fracture or subsequent osteosynthesis. Retained hardware can present significant challenges and frequently is left in place or removed in part or completely, when intraarticular in location or blocking preparation of the acetabular cavity and placement of the cup. Additional potential problems include residual deformity and malunion, persistent pelvic dissociation or nonunion of fracture fragments, cavitary or segmental bone loss from displaced or resorbed bone fragments, and occasionally occult deep infection. Preoperative assessment and planning should include careful consideration of the most appropriate surgical approach, which may be impacted by the need for hardware removal. Screening laboratory studies and aspiration of the hip may prove helpful in excluding associated deep infection. Intraoperative sciatic nerve monitoring may be of assistance in patients with partial residual nerve deficits or where extensive posterior exposure and mobilization of the sciatic nerve is needed for hardware removal or excision of heterotopic ossification. Metal cutting tools to allow partial removal of long plates and adjunctive equipment for removal of broken or stripped screws should be routinely available during these cases. Careful preoperative planning regarding implant and reconstructive options can also ensure availability of proper components and equipment. Often implants and techniques developed for revision surgery for management of major bone deficiencies are needed. Reported results suggest that surgery is frequently prolonged, can be associated with greater blood loss and may result in increased risk of post-arthroplasty heterotopic ossification when compared to routine primary procedures. Bone stock and fracture union may be better in patients with prior internal fixation than in those with nonoperative treatment of major displaced acetabular fractures. Available long-term results document more durable results with lower rates of aseptic loosening with uncemented acetabular fixation compared to cemented acetabular components. These patients are at higher risk of revision and failure than patients undergoing THA for simple osteoarthritis, though initial short-term results are comparable to conventional hip arthroplasty patients, as long as early wound healing problems and deep infection can be avoided, which is a greater risk for acute THA for initial fracture care. The application of newer implant designs, highly porous ingrowth materials, and methods for management of acetabular bone deficiency developed for revision THA have helped improve results in this challenging subset of primary THA patients

Summary. Study showed a simple acetabular placement plane formed by pelvic landmarks. The plane was adjusted by changing one of the landmarks to a fixed value for best representing the native acetabular orientation based on CT generated 3D pelvi. Introduction. Correct acetabular cup placement is a critical step to prevent dislocation in the total hip arthroplasty. There are many mechanical alignment devices available but they are usually only referencing to the body long axis and the table therefore are lack of accuracy. Recently more accurate guide was achieved by image or imageless hip navigation system. But they add more cost, steps and time. The purpose of this study was to find a simple acetabular cup placement plane by selcting bonny land marks. The plane was adjusted with a fixed value by comparing it to native acetabular orientation in CT constructed 3D pelvi. Methods. 274 anonymous CT pelvic scans from skeletally mature, normal Caucasian population with age range of 20–93 years old (mean age=64). The population included 164 males and 110 females (mean age for male=63 and female=65, P=0.40). CT data was converted to virtual bones using custom CT analytical software (SOMA™ V4.0). The acetabular anteversion angle was measured against coronal plane as AA defined by Murray. The inclination angle was measured from transverse plane. The native acetabular rim plane was constructed by three rim points of Ilium, ischium and pubis. The pelvic plane was based on and modified from previously reported alignment pelvic land marks. Anterior Inferior Iliac Spine (AIIS) was added to two local landmarks of Anterior Superior Iliac Spine (ASIS) and a point direct Lateral to Greater Sciatic Notch (LGSN). AIIS, ASIS and LGSN formed the local placement plane. The distance from three LGSN's to greater sciatic notch were 70mm, 75mm and 80mm. Three planes from three LGSN points were analyzed for anteversion and inclination angles. Results were compared with the same angles from native acetabulum. Student T test was performed with confidence level at P=0.05. Results. The mean anteversion angle/standard deviation for native acetabulum:25.7°/6.4° (male=24.6°/5.7°; female=27.3°/7.0°); plane LGSN+70mm: 21.9° /6.3°, (male= 20.3° /5.7°; female= 24.3° /6.4°); LGSN+75mm: 24.9°/6.3° (male= 23.3°/5.8°, female= 27.3°/6.2°); LGSN+80mm: 27.7°/6.1° (male= 26.1°/5.6°, female= 30.1°/6.0°). The mean inclination angle/standard deviation for native acetabulum were 51.5°/4.4° (male= 51.5°/4.2°, female= 51.5°/4.4°), plane LGSN+70mm: 51.8°/7.9° (male=53.3°/7.9°, female= 49.5°/7.4°), LGSN+75mm: 50.7°/7.8° (male= 52.3°/7.8°, female= 48.3°/7.3°); LGSN+80mm: 49.6°/7.8° (male= 51.2°/7.7°, female= 47.2°/7.2°). Student T test showed both anteversion and inclination angles of plane LGSN+75mm were not significantlydifferent from that of native acetabulum (P=0.12 and 0.11). (Table 1) The anteversion angle and inclination angle distribution are shown in Figure 1 and 2. Discussion/Conclusion. Unlike previously reported landmark methods, landmarks in this study were verified in large bone data base with exactly same measurements. The direct lateral point from GSN can be projected intraoperatively by calibrated hand along with other fixed landmarks to form an imaginative acetabular cup placement plane. This method also can be used for the imageless computer navigation as well as the mechanical alignment device

Introduction and aims. After internal hemipelvectomy for malignant pelvic tumors, pelvic reconstruction is necessary for eventual weight bearing and ambulation. Non-vascularised, fibular grafts (NVFG) offer fast, and stable reconstruction, post- modified Enneking's type I and I/IV resection. This study aimed to evaluate the success of graft union and patient function after NVFG reconstruction. Methods. From 1996 to 2009, 10 NVFG pelvic reconstructions were performed after internal hemipelvectomy in four cases of chondrosarcoma, three of Ewing's sarcoma, and single cases of osteosarcoma, malignant peripheral nerve sheath tumour, and malignant fibrous histiocytoma. A key indication for internal hemipelvectomy was sciatic notch preservation confirmed by preoperative MRI. Operation time and complications were recorded. The mean follow-up was 31.1 months (range: 5 to 56), and lower limb function was assessed using the Musculoskeletal Tumour Society scoring system. Plain radiographs and/or computer tomography were used to determine the presence or absence of NVFG union. Results. The mean operation time was four hours and 56 mins, with no major intraoperative complications and partial wound break-down in only one patient. The NVFG united successfully in all patients, with a mean union time of 7.3 months. Post-operative deep infection did not occur in any case. Seven patients were eventually able to ambulate without a cane, and overall, the average function rating percentage was 75.4%. Recurrent tumour occurred in two cases following primary resection. Death from tumour-related disease occurred in one of the ten cases. Conclusions. NVFG is a stable and reliable pelvic reconstruction method after type I and type I/IV hemipelvectomy. Reliability may be linked to preservation of graft periosteum, and careful patient selection, limited to those with an intact sciatic notch. Furthermore, the relatively short operative time required should help minimise deep infection

THA after acetabular fracture presents unique technical challenges. These challenges include bone deformity, bone deficiency, sclerotic or dysvascular bone, non-united bony fragments, pelvic discontinuity, retained hardware, heterotopic ossification, previous incisions, and concerns regarding the sciatic nerve. Despite these challenges, with current treatment methods, a high degree of success can be achieved with modern technology. Preoperative evaluation for infection - In previously operated acetabular fractures, infection is always a concern. Screening C-reactive protein and sedimentation rate may be performed. If a concern regarding infection is present, the hip may be aspirated; Incisions - In most cases, a previous incision may be utilised. If necessary, an incision may be extended or a new limb can be created and attention should be paid to maintaining optimal skin bridges. In cases with a high degree of concern about infection, a staged procedure may be considered. However, in most cases, hardware removal can be done selectively at the time of THA surgery. Hardware that does not compromise placement of the THA may be left in place. Sometimes hardware can be cut off within the acetabulum to minimise exposure needs. The reconstructive goal is to place the hip center as close as possible to normal hip center but also to gain good support of the socket on host bone. In most cases, both goals can be met. When necessary, some compromise in hip center of rotation may be considered to optimise implant stability on host bone. The principles of revision surgery are followed using uncemented acetabular components fixed with augmentation screws. Most bone deficiencies may be managed with methods similar to revision hip surgery. However, in the acetabular fracture patient, usually the host femoral head is available and this can be used as bone graft, either in particulate or bulk form. Most cavitary deficiencies can be dealt with particulate bone graft. Some superolateral bone deficiencies from posterior wall fractures may be considered for bone grafting or augmentation techniques. Nonunited fractures are not uncommon in these circumstances. Small wall nonunions may be managed as noted above for bone deficiency. If pelvic discontinuity is present, it is usually best treated by following the rules established for treatment of pelvic discontinuity with pelvic plating. Pelvic plating provides a reasonable likelihood of bone healing in these circumstances when combined with bone grafting techniques. Heterotopic ossification is common in previously operated acetabular fractures. Removal of heterotopic bone at the time of surgery to gain hip motion is routine. Postoperative measures to reduce the likelihood of bone formation (that is either shielded radiation or use of a nonsteroid anti-inflammatory agent) may be strongly considered. The sciatic nerve is at risk during these procedures. In many cases, avoiding the nerve and the region of the nerve is a reasonable approach. When a lot of work must be done on the posterior column, the surgeon needs to know exactly where the nerve is and in such cases the nerve may be exposed distally beneath the gluteus maximus tendon and followed proximally with careful and judicious dissection. Results of total hip arthroplasty after acetabular fracture have varied in the past. More recent series have shown a high rate of acetabular fixation associated with uncemented hemispherical implants. Acetabular fracture patients are disproportionately young and active with unilateral hip disease and, therefore, bearing surfaces should be chosen accordingly

Aims. The aim of this study was to optimize screw hole placement in an acetabulum cup implant to improve secondary initial fixation by identifying the region of thickest acetabulum bone. The “scratch fit” of modern acetabular cup implants with highly porous coatings is often adequate for initial fixation in primary total hip arthroplasty. Initial fixation must limit micromotion to acceptable levels to facilitate osseointegration and long term cup stability. Secondary initial fixation can be required in cases with poor bone quality or bone loss and is commonly achieved with bone screws and a cup implant with multiple screw holes. To provide maximum secondary initial fixation, the cup screw holes should be positioned to allow access to the limited region of thick pelvic bone. Patients and Methods. Through a partnership with Materialise, a statistical shape model of the pelvis was created utilizing 80 CT scans (36 female, 44 male). To limit the effect of variation outside the area of cup implant fixation, the shape model includes only the inferior pelvis (cut off at the greater sciatic notch and above the anterior inferior iliac spine). A virtual implantation protocol was developed which creates instances of the pelvis shape model that accurately simulate the intraoperative reaming of the acetabulum to accept the cup implant. First a sphere is best fit to the native acetabulum and the diameter is rounded to the nearest whole millimeter. The diameter of the best fit sphere is increased by 1mm to simulate bone removal during the spherical reaming procedure. The sphere is translated medially and superiorly such that it is tangent to the teardrop and removes 2mm of superior acetabulum. The sphere is used to perform a Boolean subtraction from the shape model to create a virtually reamed pelvis shape model. The Materialise 3-Matic software was used to perform a thickness analysis of the prepared shape models. The output of the thickness analysis is displayed as a color “heat map” where green represents thin bone and red is thick bone. The region of thickest bone was identified and used to drive ideal screw hole placement in the cup implant to access this region. Results. The analysis finds there is a limited arc of thick bone in the acetabulum that begins superiorly and extends posterior-inferior that accounts for only about 15% of total reamed surface area. Maximum screw purchase is provided when screw holes in the cup implant are placed over this limited region of thick bone. The thickest bone, located superiorly, facilitates the placement of a long bone screw up the iliac column and the posterior-inferior region of thick bone facilitates the placement of additional posterior screws. Conclusion. The shape model development, virtual implantation protocol, and heat map thickness analysis allowed the placement of bone screw holes directly over the limited region of thick pelvic bone. This allows maximum screw purchase which is important in achieving adequate secondary initial fixation with bone screws. Disclaimer. Author is an engineer employed by DJO Surgical who funded this study

Introduction. Regional anesthesia is commonly utilized to minimize postoperative pain, improve function, and allow earlier rehabilitation following Total Knee Arthroplasty (TKA). The adductor canal block (ACB) provides effective analgesia of the anterior knee. However, patients will often experience posterior pain not covered by the ACB requiring supplemental opioid medications. A technique involving infiltration of local anesthetic between the popliteal artery and capsule of knee (IPACK) targets the terminal branches of the sciatic nerve, providing an alternative for controlling posterior knee pain following TKA. Materials and Methods. IRB approval was obtained, a power analysis was performed, and all patients gave informed consent. Eligible patients were those scheduled for an elective unilateral, primary TKA, who were ≥ 18 years old, English speaking, American Society of Anesthesiologists physical status (ASA PS) classification I-III. Exclusion criteria included contraindication to regional anesthesia or peripheral nerve blocks, allergy to local anesthetics, allergy to nonsteroidal anti-inflammatory drugs (NSAIDs), chronic renal insufficiency with GFR < 60, chronic pain not related to the operative joint, chronic (> 3 month) opioid use, pre-existing peripheral neuropathy involving the operative limb, and body mass index (BMI) ≥ 40 kg/m. 2. . Patients were randomized into one of two treatment arms: Continuous ACB with IPACK (IPACK Group) block or Continuous ACB with sham subcutaneous saline injection (No IPACK Group). IPACK Group received single injection of 20 mL 0.25% Ropivacaine. Postoperatively, all patients received a standardized multimodal analgesic regimen. The study followed a double-blinded format. Only the anesthesiologist performing the block was aware of randomization status. Following surgery, a blinded medical assessor recorded cumulative opioid consumption, average and worst pain scores, and gait distance. Results. 72 people were enrolled in the study and three withdrew. There were 35 people in the IPACK group and 34 in the NO IPACK group. There was no difference demographically between the groups. In the Post Anesthesia Care Unit (PACU), the average (P=0.0122) and worst (P=0.0168) pain scores at rest were statistically lower in the IPACK group. There was no difference in the pain scores during physical therapy. (P=0.2080) There was no difference in opioid consumption in the PACU (P=0.7928), at 8 hours (P=0.2867), 16 hours (P=0.2387), 24 hours (P=0.7456), or 30 hours (P=0.8029). There was no difference in pain scores on POD 1 in the AM (P=0.4597) or PM (P=0.6273), nor was there any difference in walking distance (P=0.5197). There was also no difference in length of stay in the PACU (P=0.9426) or hospital (P=0.2141) between the two groups. Discussion/Conclusion. Overall, pain was well controlled between the two groups. The IPACK group had lower pain scores at rest in the PACU, but this may not be clinically significant. The routine use of the IPACK is not supported by the results of this study. There may be use of the IPACK block as a rescue block or in patients whom have contraindications to our standard multimodal treatment regimen, or in patients with chronic pain or opioid dependence

Background. Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip is a technically demanding procedure. Restoration of the anatomical hip center frequently requires limb lengthening in excess of 4 cm and increases the risk of neurologic traction injury. However, it can be difficult to predict potential leg length change, especially in total hip arthroplasty for Crowe type IV developmental hip dysplasia. The purpose of the present study was to better define features that might aid in the preoperative prediction of leg length change in THAs with subtrochanteric femoral shortening osteotomy for Crowe type IV developmental dysplasia of the hip. Patients and Methods. Primary total hip arthroplasties with subtrochanteric femoral shortening osteotomy were performed in 70 hips for the treatment of Crowe type IV developmental hip dysplasia. The patients were subdivided into two groups with or without iliofemoral osteoarthritis. Leg length change after surgery was measured radiographically by subtracting the amount of resection of the femur from the amount of distraction of the greater trochanter. Preoperative passive hip motion was retrospectively reviewed from medical records and defined as either higher or lower motion groups. Results. The preoperative flexion of patients without iliofemoral osteoarthritis was significantly higher than for patients with iliofemoral osteoarthritis. All hips without iliofemoral OA had higher motion. The preoperative flexion in the higher motion group both with and without iliofemoral OA was significantly greater than in the lower group with iliofemoral OA (Figure 1). Leg length change in patients without iliofemoral osteoarthritis was significantly greater than with iliofemoral osteoarthritis (Figure 2), and the higher hip motion group had greater leg length change in THA than the lower motion group. No clinical evidence of postoperative neurologic injury was observed in patients with iliofemoral OA. Postoperative transient calf numbness in the distribution of the sciatic nerve was observed in 2 of 25 hips without iliofemoral OA (8.0%), however, no sensory and motor nerve deficit was observed. Discussion. The authors hypothesized that preoperative hip motion could affect soft tissue contractures, and our findings suggest that the soft tissues surrounding the hip joint with iliofemoral OA should be more contracted than the hip without OA. We also found leg length change in the higher motion group was greater than in the lower motion group. Previous studies reported limb lengthening in excess of 4 cm could increase the risk of nerve palsy. Transient calf numbness in the distribution of the sciatic nerve was observed in 2 hips without iliofemoral OA and their leg length change was not greater than 4 cm. Our findings suggest that hips without iliofemoral OA should be paid attention to protect the nerves from excessive elongation. The current study identifies several features that might help predict leg length change during the preoperative planning of total hip arthroplasty for Crowe type IV developmental hip dysplasia

Total hip arthroplasty (THA) is reliable and reproducible in relieving pain and improving function in patients with end-stage arthritis of the hip joint. With improvements in surgical technique and advances in implant and instrument design, there has been a shift in focus from the technical aspects of the surgical procedure to improving the overall patient experience. In addition, shifts in medico-economic trends placed a premium on early patient mobilization, early discharge, and maximizing patient satisfaction. Arguably, a single most important advance in arthroplasty over the past 2 decades has been the development of multimodal pain protocols that form the foundation of many of the rapid recovery protocols today. The principal concept of multimodal analgesia is pain reduction through the utilization of multiple agents that synergistically act at various nodes of the pain pathway, thus, minimizing patient exposure to each individual agent and opioids in order to prevent opioid related adverse events (ORAE). Regional anesthesia has been shown to reduce post-operative pain, morphine consumption, and nausea and vomiting compared to general anesthesia but not length of stay. Additionally, general anesthesia has been shown to be associated with increased rates of post-operative adverse events, The use of peripheral nerve blocks in the form of sciatic, femoral or fascia iliaca blocks have not been shown to significantly reduce post-operative pain compared to controls. Periarticular infiltration of local anesthetics has been shown in some settings to reduce pain during the immediate post-operative period (<24 h). However, no significant differences were noted in terms of early recovery or complications. The use of liposomal bupivacaine (LB) local infiltration decreased pain and shortened length of stay comparable to patients receiving a fascia iliaca compartment block, and has been shown in relatively few randomised trials to provide improved pain relief at 24 hours only compared to conventional bupivacaine. Continuous intra-articular infusion of bupivacaine after THA did not significantly further reduce post-operative pain compared to placebo. In summary, the use of regional anesthesia when appropriate along with local anesthetic infiltration in the setting of a robust multimodal pain protocol minimises pain and complications while maximizing patient satisfaction following THA