Gluteal Tendinopathy is a poorly understood condition that predominantly affects post-menopausal women. It causes lateral hip pain, worse when lying on the affected side or when walking up a hill or stairs. It has been labelled ˜Greater Trochanteric Pain Syndrome” a name that recognises the lack of understanding of the condition. Surgical reconstruction of the gluteal cuff is well established and has been undertaken numerous times over the last 16 years by the senior author (AJL). However, the quality of collagen in the tendons can be very poor and this leads to compromised results. We present the results of gluteal cuff reconstruction combined with augmentation using a bioinductive implant. 14 patients (11 female, 3 male; mean age 74.2 ± 6.3 years) with significant symptoms secondary to gluteal tendinopathy that had failed conservative treatment (ultrasound guided injection and structured physiotherapy) underwent surgical reconstruction by the senior author using an open approach. In all cases the iliotibial band was lengthened and the trochanteric bursa excised. The gluteal cuff was reattached using Healicoil anchors (3–5×4.75mm anchors; single anchors but double row repair) and then augmented using a Regeneten patch. Patients were mobilised fully weight bearing post-operatively but were asked to use crutches until they were no longer limping. All had structured post-surgery rehabilitation courtesy of trained physiotherapists. There were no post-operative complications and all patients reported an improvement in pain levels (Visual Analogue Scale 7.8 pre-op; 2.6 post-op) and functional levels (UCLA Activity Score 3.5 pre-op; 7.1 post-op) at 6 months post surgery. Surgery for gluteal tendinopathy produces good outcomes and the use of Regeneten as an augment for poor quality collagen is seemingly a safe, helpful addition. Further comparative studies would help clarify this

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

After total hip replacement, force generating capacity of gluteal muscles is an impotant parameter on joint contact forces and primary fixation of total hip replacement. Femoral offset is an option to optimize muscle moment arms, especially main abductor Gluteus Medius and Minimus. To investigate relationship with weak gluteal muscles (Gluteus Medius and Minimus) and increased femoral offset, we build a musculoskeletal model. Creating of three-dimensional femur geometry and scaling of the musculoskeletal model according to the subject were performed with computed tomography data. Obtained gait kinematic and kinetic data were applied and to mimic gluteal muscle weakness, the force generating capacities of Gluteus Medius and Minimus reduced (%20-%80). Analysis were done for both anatomical and +10mm offset. Then, muscle and joint reaction forces obtained from musculoskeletal analysis transfered to CT based finite element model to evaluate changes in maximum principle stresses on femur. According to the results of the musculoskeletal analysis, the weakness of the gluteal muscles caused an increase in the activation of Gluteus Maximus, Rectus Femoris and Tensor Fasciae Latae. Effects of +10 mm femoral offset on total abductor muscle activity increased with reduced muscle strength. As a result of the finite element analysis, no significant difference was observed for maximum principle stresses on femur with varying muscle activites. The results of these analyses are important to understand weakness of gluteal muscles and for planning hip surgery

Severe and recalcitrant Greater Trochanteric Pain Syndrome (GTPS), previously known as Trochanteric bursitis, has been associated with torn gluteal tendons. The aim of this study was to assess the physical, functional and quality of life outcomes of combined bursectomy and gluteal tendon reconstructive surgery. 24 patients underwent combined bursectomy and gluteal tendon reconstruction under one surgeon. They were contacted by mail, email, and telephone. 16 were available for examination, two had revision surgery, one had interview only, one moved interstate, one declined and three were lost to follow up. An independent standardised assessment was undertaken. Hip muscle strength was measured by hand-held dynamometry. Trendelenburg sign was measured according to Hard-castle’s protocol and by observing gait. Functional and quality of life measures were assessed via the Harris Hip Score and the Oswestry Disability scale. Pain and satisfaction was measured via a 10cm visual analogue scale. All patients were female. The mean time from surgery was 18.9 months +/− 8.50. 10 had right sided surgery. The two patients who had revision surgery are not included in this data. Strength of hip abduction was weaker on the ipsilateral side (p< =.05). External rotation appeared to be weaker, however this was not statistically significant. Hardcastle’s single leg standing Trendelenburg sign was shorter on the ipsilateral side (16.3secs +/− 12.3 vs 22.1secs +/− 10.1, p< =.05). Five patients had an ipsilateral Trendelenburg gait, two had a contralateral Trendelen-burg gait. The mean recalled preoperative pain score was 67.73 +/− 31.51 out of 100. The mean post operative score was 14.44 +/− 16.1 (p< =.0005). Patient satisfaction with the results of surgery was rated at 80.7 +/−17.69, out of 100. With regard to function, the mean post operative Harris hip score was 70.9 +/− 25.73 out of 91, and the Oswestry disability score was 15.5 +/− 11.39, out of 100 where a low score indicates better outcome. Combined bursectomy and gluteal tendon reconstruction appears to be an effective procedure for the relief of pain in patients with recalcitrant GTPS in most patients. High patient satisfaction levels suggest that function and quality of life are improved following surgery. A prospective longitudinal study has commenced to verify these results

We examined the position of the superior gluteal nerve in forty-four cadaveric hips in relation to the greater trochanter and the acetabulum . We found that the nerve lay a mean of 4.8 centimetres from the greater trochanter with a range of two to nine centimetres and a mean of 3.2 centimetres from the acetabulum. The nerve was visibly damaged in three out of forty-four hips following direct lateral approach. Our study does not support the “safe zone” proximal to the greater trochanter and suggests the proximity of the nerve to the acetabulum as a potential cause of nerve injury. Abductor weakness following the direct lateral approach to the hip is well described and is associated with damage to the superior gluteal nerve on neurophysiological testing in from 23–26 %. A “safe zone” has been described of up to five centimeters proximal to the greater trochanter. We examined forty-four cadaveric hips exposed by the direct lateral approach by surgeons not directly involved with the study. We measured the position of the superior gluteal nerve in relation to the greater trochanter, the acetabulum and the margin of the skin incision. We examined the nerve for visible signs of damage. We found the position of the superior gluteal nerve to be a mean of 4.8 centimeters from the greater trochanter (range two to nine), 3.2 centimeters from the superior margin of the acetabulum (range one to eight), and 4.1 centimeters from the margin of the skin incision. There was visible damage to the nerve in three of forty-four cases. Neurophysiological studies show subclinical damage to the superior gluteal nerve in up to 77% of cases following direct lateral approach to the hip and in association with abductor weakness in 23–26%. Our study does not support the notion of a “safe zone” of five centimetres proximal to the greater trochanter, and with a mean of 4.8 centimetres the zone is unsafe more often than it is safe. The proximity of the superior gluteal nerve to the superior margin of the acetabulum suggests that it may be damaged by retractor placement at this site

Trochanteric bursitis is initially treated with local anaesthetic and corticosteroid injections but when this fails there are few interventions that relieve the symptoms. We report a new surgical technique for refractory trochanteric bursitis in 43 patients. Fourteen patients had developed trochanteric bursitis after primary total hip arthroplasty (THA), 6 after revision THA, 17 for no definable reason (idiopathic) and 7 after trauma. Follow up ranged from six months to 15 years (mean five years). Outcome was measured by pre and post operative Oxford Hip Scores. The mean post operative decreases were 23 points in traumatic cases, 13 in idiopathic and 13 for patients after primary THA. A mean increase of 3 was observed in patients after revision THA. The operation relieved symptoms in 75%. The outcome depended on aetiology. 100% of traumatic, 88% of idiopathic and 64% after primary THA were successful. All operations after revision THA were unsuccessful. This is the largest series of a single surgical technique for refractory trochanteric bursitis and the only one to subdivide the outcome by aetiology. Transposition of the gluteal fascia is indicated in patients with idiopathic, traumatic and post primary THA trochanteric bursitis, but not after revision THA

Aims

The gluteus minimus (GMin) and gluteus medius (GMed) have unique structural and functional segments that may be affected to varying degrees, by end-stage osteoarthritis (OA) and normal ageing. We used data from patients with end-stage OA and matched healthy controls to 1) quantify the atrophy of the GMin and GMed in the two groups and 2) describe the distinct patterns of the fatty infiltration in the different segments of the GMin and GMed in the two groups.

Aims. Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH. Methods. Patients were divided into four groups: A, adolescents who had not undergone surgery for DDH in childhood (25 hips); B, adolescents who had undergone surgery for DDH in childhood (20 hips); C, adults with DDH who had not undergone previous surgery (80 hips); and D, a control group of patients with healthy hips (70 hips). The radiological evaluation of digital anteroposterior views of hips included the Wiberg angle (centre-edge angle (CEA)), femoral head cover (FHC), medialization, distalization, and the ilioischial angle. Clinical assessment involved the Harris Hip Score (HHS) and gluteal muscle performance assessment. Results. Significant improvements in radiological parameters were achieved in all measurements in all groups (p < 0.05). The greatest improvement was in CEA (mean of 19° (17.2° to 22.3°) in Group B), medialization (mean of 3 mm (0.9 to 5.2) in Group C), distalization (mean of 6 mm (3.5 to 8.2) in Group B), FHC (mean of 17% (12.7% to 21.2%) in Group B), and ilioischial angle (mean of 5° (2.3° to 8.1°) in Group B). There were significant improvements in the mean HHS and gluteal muscle performance scores postoperatively in all three groups. Conclusion. The greatest correction of radiological parameters and clinical outcomes was found in patients who had undergone hip surgery in childhood. Although the surgical treatment of DDH in childhood makes subsequent hip surgery more difficult due to scarring, adhesions, and altered anatomy, it requires less correction of the deformity and has a beneficial effect on the outcome of PAO in adolescence and early adulthood. Cite this article: Bone Joint J 2022;104-B(7):775–780

Introduction and Objective. The human body is designed to walk in an efficient way. As energy can be stored in elastic structures, it is no surprise that the strongest elastic structure of the human body, the iliofemoral ligament (IFL), is located in the lower limb. Numerous popular surgical hip interventions, however, affect the structural integrity of the hip capsule and there is a growing evidence that surgical repair of the capsule improves the surgical outcome. Though, the exact contribution of the iliofemoral ligament in energy efficient hip function remains unelucidated. Therefore, the objective of this study was to evaluate the influence of the IFL on energy efficient ambulation. Materials and Methods. In order to assess the potential passive contribution of the IFL to energy efficient ambulation, we simulated walking using the large public dataset (n=50) from Schreiber in a the AnyBody musculoskeletal modeling environment with and without the inclusion of the IFL. The work required from the psoas, iliacus, sartorius, quadriceps and gluteal muscles was evaluated in both situations. Considering the large uncertainty on ligament properties a parameter study was included. Results. A significant reduction in the active component of all hip flexors was observed when the IFL is intact. The required muscle work was found to be reduced by as much as 48% (CI: 29–62%), 61% (CI: 35–84%) and 38% (CI: 2–69%) for the psoas, iliacus, and sartorius muscle respectively. The IFL inclusion has no major effect on the required work from the quadriceps and the gluteal muscle group. The energy storage in the IFL is largest at maximal hip extension and the contribution to forward motion is the largest at the start of the swing phase. Conclusions. The iliofemoral ligament seems to be a crucial structure in energy efficient walking. The findings support need for meticulous reconstruction of the capsule ligament in case of surgical damage

Aims. The aim of the HIPGEN consortium is to develop the first cell therapy product for hip fracture patients using PLacental-eXpanded (PLX-PAD) stromal cells. Methods. HIPGEN is a multicentre, multinational, randomized, double-blind, placebo-controlled trial. A total of 240 patients aged 60 to 90 years with low-energy femoral neck fractures (FNF) will be allocated to two arms and receive an intramuscular injection of either 150 × 10. 6. PLX-PAD cells or placebo into the medial gluteal muscle after direct lateral implantation of total or hemi hip arthroplasty. Patients will be followed for two years. The primary endpoint is the Short Physical Performance Battery (SPPB) at week 26. Secondary and exploratory endpoints include morphological parameters (lean body mass), functional parameters (abduction and handgrip strength, symmetry in gait, weightbearing), all-cause mortality rate and patient-reported outcome measures (Lower Limb Measure, EuroQol five-dimension questionnaire). Immunological biomarker and in vitro studies will be performed to analyze the PLX-PAD mechanism of action. A sample size of 240 subjects was calculated providing 88% power for the detection of a 1 SPPB point treatment effect for a two-sided test with an α level of 5%. Conclusion. The HIPGEN study assesses the efficacy, safety, and tolerability of intramuscular PLX-PAD administration for the treatment of muscle injury following arthroplasty for hip fracture. It is the first phase III study to investigate the effect of an allogeneic cell therapy on improved mobilization after hip fracture, an aspect which is in sore need of addressing for the improvement in standard of care treatment for patients with FNF. Cite this article: Bone Jt Open 2022;3(4):340–347

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

The aim of the study was to evaluate radiological and clinical outcomes of surgical treatment of developmental dysplasia of the hip (DDH) with Periacetabular Osteotomy (PAO) and to determine the values of radiological parameters allowing us to obtain an optimal clinical result. Radiological evaluation included a standardized AP digital radiograph of the hip joints. Centre edge angle (CEA), medialization, distalization, femoral head coverage (FHC) and ilioischial angle were measured. Clinical evaluation based on HHS, WOMAC, Merle d'Aubigne-Postel scales and Hip Lag Sign. Radiological and clinical evaluation was performed preoperatively and approximately 12 months after the surgery. Statistically significant (p<0.05) differences in radiological measurements and all clinical scales have been observed pre- and postoperatively for all of the parameters. The results of PAO presented decreased medialization by 3.4mm (range: 3 to 3.7), distalization by 3.5mm (range: 3.2 to 3.8) and the ilioischial angle by 2.7° (range: 2.2 to 3.7). There was also an improvement in the femoral head bone coverage: CEA increased by 16.3° (range: 12.1˚ to 20.5˚) and FHC by 15.2% (range: 10.8 to 19.8). Clinically we observed an increase in HHS by 22 points (range: 15.8 to 28.2) and M. Postel d'Aubigne by 3.5 points (range: 2.0 to 4.4) and a decrease in WOMAC by 24% (range: 22.6 to 25.8). HLS improvement of gluteal muscles’ efficiency has been observed in 67% of patients postoperatively. This study revealed that the qualification of patients with DDH for an elective PAO is more justified due to the predicted optimal clinical outcomes based on three parameters: CEA <25 degrees, FHC <75%, and ilioischial angle >85.9 degrees. Accordingly, to achieve better clinical results for all scales, it is necessary to increase the average CEA value by 11˚, the average FHC by 11%, and reduce the average ilioischial angle by 3˚

The direct anterior approach (DAA) is a popular minimally invasive approach for total hip arthroplasty (THA). It usually involves ligation of the lateral femoral circumflex artery's ascending branch (a-LFCA), which contributes to the perfusion of the tensor fasciae latae (TFL) muscle. Periarticular muscle status and clinical outcome were assessed after DAA-THA after a-LFCA preservation versus ligation. We evaluated surgical records of 161 patients undergoing DAA-THA with tentative preservation of the a-LFCA by the senior author between May and November 2021. Among 92 eligible patients, 33 (35 hips) featured successful preservation, of which 20 (22 hips, 13 female) participated in the study. From 59 patients with ligated a-LFCA, 26 (27 hips, 15 female) were enrolled, constituting the control group. MRI and clinical examinations were performed at 17–26 months to analyze volume and fatty infiltration of the TFL, gluteus medius and gluteus minimus muscles relative to the contralateral non-THA hip (15 preserved, 18 ligated). Clinical and radiographic data was retrospectively extracted from patient files. Patient-reported outcomes (PROMs) were added from the THA registry. There was a relative difference in TFL muscle volume of -6.27 cm. 3. (−9.89%, p=0.018) after a-LFCA preservation versus -8.6 cm. 3. (=11.62%, p=0.002) after ligation, without group differences (p>0.340). a-LFCA preservation showed lower relative TFL fatty infiltration (p=0.10). Gluteal muscle status was similar between sides and groups. Coxa valga morphology was more frequent in a-LFCA preservation (83%) than ligation (17%). Clinical outcomes showed high patient satisfaction in both groups, without difference in PROMs, but less anterolateral soft-tissue swelling after a-LFCA preservation (p<0.001). Despite excellent clinical results in both groups, preservation of the a-LFCA was associated with less TFL fatty infiltration and soft tissue swelling. Provided there is no compromise of intraoperative access we recommend a-LFCA preservation for DAA-THA

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

Topographic anatomy and general distribution of LFCA is well described in anatomy textbooks. Its contribution to the vascularization of specific anatomic structures in the hip region is poorly defined. The purpose of this study was to demonstrate the importance of LFCA in hip circulation, especially in the vascularization of hip abductors. The LFCA was specifically studied in 30 hips from 26 fresh cadavers after injection of common iliac artery or aorta with colored silicone for a more extensive hip vascular study. 24 hours after intra-arterial setting of silicone, dissection was performed through the anterior iliofemoral approach to expose the artery and its branches from the origin to the terminal distribution. In all specimens, the ascending branch of the LFCA was found as consistent supplier of gluteus minimus, gluteus medius, and tensor fasciae latae muscles by a variable number of branches. The proximal part of the abductor muscles was mainly supplied by the superior gluteal artery. We conclude, that ligating the ascending branch of the LFCA during anterior approach to the hip joint is likely to affect the vascularity and function of the abductor muscles especially in situations when perfusion of these muscles by the superior gluteal artery is compromised

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