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

Transposition osteotomy of the acetabulum (TOA) was the first periacetabular osteotomy for the osteoarthritis hips due to acetabular dysplasia, in which the acetabulum was transposed with articular cartilage. TOA improves coverage of the femoral head to restore congruity and stability, and also prevent further osteoarthritis deterioration and induce regeneration of the joint. Many good clinical outcomes have been reported for such periacetabular osteotomies for osteoarthritis of the hips at an early stage. In contrast, the clinical outcome is controversial for those hips at an advanced stage, in which the joint space has partly disappeared. The purpose of this study was to investigate whether TOA is an appropriate option for treatment of osteoarthritis of the hips at the advanced stage by comparing with matched control hips at the early stage. Between 1998 and 2001, TOA was performed in 104 hips of 98 patients. Sixteen of 17 hips (94%) with osteoarthritis at the advanced stage were examined and compared with 37 matched control hips at the early stage. The mean age at the operation was 48(38–56) and the mean follow-up period was 88 (65–107) months. TOA corrected the acetabular dysplasia and significantly improved containment of the femoral head. No hips had secondary operations including THA. Clinical scores were also significantly improved in both of the groups. In the advanced osteoarthritis cases, there was a tendency for abduction congruity before transposition osteotomy of the acetabulum to reflect the clinical outcome. TOA is a promising treatment option for the advanced osteoarthritis of the hips as well as for those patients at the early stage when preoperative radiographs show good congruity or containment of the joint

Competence of the extensor mechanism is the major determinant of functional outcome after resection of the proximal tibia and tumor prosthesis implantation. Restoration of a compromised active extension of the knee and an extension lag still remains a difficult challenge. Various techniques have been proposed in the past twenty years including direct attachment of the patellar ligament to the prosthesis, transposition of the medial gastrocnemius muscle possibly associated with other muscle flaps, transposition of the fibula and combination of these techniques. Transposition of the fibula was first reported by Kotz in 1983 but not sufficiently described, so that surgeons who want to plane and manage such a procedure can have some difficulties. We present our technique of fibula transposition and report the functional results about seven patients treated for high-grade sarcomas of the proximal tibia. Fibula transposition is carried out only if the entire fibula and its soft-tissues can be preserved. Resection of the tumor and reconstruction is carried out using the same anteromedial approach. After implantation of the prosthesis, the fibula and its muscles are mobilized anteriorly in a ‘baionnette’ shape obtained by performing a two-level osteotomy. The peroneal nerve and the anterior tibial vessels are previously identified and released to prevent tension on these structures during transposition. Care must be taken to preserve as much as possible the muscular insertions on the fibula so that probability of bone fusion increases. The biceps tendon and the lateral collateral ligament inserted in the fibular head are sutured to the patellar ligament. The knee is immobilized in a knee-ankle orthosis for 6 weeks. We have performed this technique in seven cases. A medial gastrocnemius muscle flap was associated in 3 cases to cover the prosthesis. Fusion was achieved in all cases. Full active extension was obtained in all cases with an extensor strength rated 5/5. All patients were ambulatory without external support at the last follow up

Although periacetabular osteotomies are widely used for the treatment of symptomatic acetabular dysplasia, the surgical outcomes after long term follow-up are still limited. Thus, we assessed hip survival and patient-reported outcomes (PROMs) at 20 years after the transposition osteotomy of acetabulum (TOA).

Among 260 hips in 238 patients treated with TOA, 172 hips in 160 patients were evaluated at average 20.8 years, excluding patients who died or lost to follow-up. Kaplan-Meier analysis was used to assess survivorship with an end-point of THA. PROMs were evaluated using the VAS satisfaction, VAS pain, Oxford hip score (OHS), and Forgotten joint score (FJS). The thresholds of favorable outcomes of FJS and OHS were obtained using the receiver-operating characteristic curve with VAS satisfaction ≥ 50 and VAS pain < 20 as anchors.

Thirty-three hips (19.2%) underwent THA at average 13.3 years after TOA. Kaplan-Meier analysis revealed hip survival rate at 20 years was 79.7%. Multivariate analysis showed the preoperative Tönnis grade significantly influenced hip survival. Survival rates with Tönnis grade 0, grade 1, and grade 2 were 93.3%, 86.7%, and 54.8% at 20 years, respectively. More than 60% of the patients showed favorable PROMs (VAS satisfaction ≥ 50, VAS pain < 20, OHS ≥ 42, FJS ≥ 51). Advanced Tönnis grade at the latest follow-up and higher BMI were significantly associated with unfavorable OHS, but not with other PROMs.

This study demonstrated the durability of TOA for hips with Tönnis grade 0–1 and favorable satisfaction in majority of the patients at 20 years after surgery. Current presence of advanced osteoarthritis is associated with the lower hip function (OHS), but not necessarily associated with subjective pain and satisfaction. Higher BMI also showed a negative impact on postoperative function.

Aim: The purpose of the present retrospective study was to evaluate reasonable routine transposition of the ulnar nerve in bicondylar humeral fractures.

Material and method: From 1996 to 2007 112 bicondylar fractures were operated. 88 pateints (47 women and 41 men) were followed up for average 56 months. Average age was 48 (14–80) years. Open fractures were 17. Fractures were distributed by the AO classification as follows: type C1.2 – 16, C1.3 – 10, C2.1 – 22, C2.2 – 7, C2.3 – 3, C3.1 – 17, C3.2 – 8 and C3.3 -5. All fractures were operated by the AO method with dorsal approach, osteotomy of the olecranon (83 fractures) and fixation with 2 plates. In 47 cases the ulnar nerve was routinely anteriorly transposed and for the rest 41 patients transposition was not done.

Results: From 47 patients with routine anterior transposition 7 had Mc Gowan I dysfunction that was resolved in 3 months. From 41 patients without transposition 9 had a type Mc Gowan I dysfunction. There was no statistical significance between the two groups. (p> 0,05). However, 12 to 18 months later 3 patients from the group without transposition with type C1.3, C3.1 and C3.3 fractures returned with late postoperative nerve palsy Mc Gowan II and III. They were treated by neurolysis and transposition.

Conclusion: Routine anterior transposition of the ulnar nerve is not reasonable in every type of bicondylar humeral fractures. The type of the bicondylar fracture defines whether the nerve transposition is reasonable or not. In low bycondilar humeral fractures and type C3 fractures the nerve transposition is obligatory.

Ulnar compression neuritis at the elbow level, known as the cubital syndrome, is one of the most common nerve entrapment syndromes. There are many treatment alternatives, such as conservative treatment, submuscular transposition, simple facial release, medial epicondylectomy and anterior subcutaneous transposition. The aim of the present study is to suggest the intramuscular transposition of the ulnar nerve for the cubital syndrome treatment.

With the technique based on flaps creation by “Z” lengthening of the flexorpronator muscules, the ulnar nerve is transferred in a well vascularizated area. Between 1992 and 2001, 76 patients were treated by anterior intramuscular transposition of the ulnar nerve. It was possible to follow up 27 patients, 19 males and 8 females. During the re-examination, the rough and thin grasping, the improved objective and subjective sings, as well as the return to the previous vocation, were reported. We make comparison with the international bibliography and correlation of the results to the age of the patients.

We recommend the anterior intramuscular transposition of the ulnar nerve for the cubital tunnel syndrome treatment, which is technically demanding, but provides a satisfactory functional outcome.

The purpose of this study was to evaluate the results of subcutaneous ulnar nerve transposition in the treatment of Cubital Tunnel Syndrome (CTS) and the influence of prognostic factores such as preoperative McGowan stage, age and duration of symptoms.

36 patients (17 men and 19 women) with CTS who underwent subcutaneous ulnar nerve transposition between 2006 and 2009 were evaluated postoperatively, an average follow-up of 28 months. Sensory and motor recovery was evaluated clinically. The postoperative outcome was based on modified Bishop score, subjective assessment of function and on the degree of patient satisfaction. The dominant side was involved in 61% cases and the mean age was 51.2 years. There were 9 (25%) McGowan stage I, 18 (50%) stage II and 9 stage III patients.

We used the Mann-Whitney and Kruskal-Wallis test to compare continuous variables and chi-square and Fisher Exact Test for categorical variables.

There was a statistically significant improvement of sensory (p=0.02) and motor (p=0.02) deficits. We obtained 21 (58.3%) excellent results, seven (19.4%) fair, six (16.7%) satisfactory, and two bad ones (5.55%). There was a statistically significant improvement of function (p<0.001).

There is controversy in the literature regarding the best surgical treatment for CTS. The duration and severity of symptoms and advanced age, more than the surgical technique, seem to influence prognosis. With the technique used, the satisfaction rate was 86% and 72% recovered their daily activities without limitations. 78% of patients with severe neuropathy improved after surgery. The rates of postoperative complications were comparable with those of other studies. The severity of neuropathy and duration of symptoms (>12months) pre-operatively, but not age, had a negative influence on the outcome.

The results showed that the subcutaneous ulnar nerve transposition is safe and effective for postoperative clinical sensory and motor recovery for several degrees of severity in CTS. Given the major prognostic factors, surgical treatment should be advocated as soon as axonal loss has become clinically evident.

Aims: Ulnar nerve compression at the elbow known as cubital tunnel syndrome is the second most common compression neuropathy of the upper limb. There is currently no consensus on the optimal operative treatment approach. The objective of this meta-analysis of randomized controlled trials was to evaluate the efficacy of simple decompression versus anterior transposition of the nerve in the treatment of cubital tunnel syndrome.

Methods: Multiple databases (Medline, Embase, Cochrane Library, Cinahl and several meeting archives) were searched for randomized controlled trials (RCTs) reporting on the outcome of operative treatment of cubital tunnel syndrome in patients with no trauma or previous surgeries. Two reviewers abstracted baseline characteristics, clinical scores and motor nerve conduction velocities independently. Data were pooled across studies, standard mean differences in effect sizes (SMD) weighted by study sample size were calculated and heterogeneity across studies was assessed.

Results: We identified four RCTs comparing simple decompression to anterior ulnar nerve transposition (two submuscular and two subcutaneous). Three studies used a clinical scoring system as the primary clinical outcome (n=261). There were no significant differences between simple decompression and anterior transposition. (SMD= − 0.04, 95%CI: −0.36 to 0.28, p=0.81). We did not find significant heterogeneity across studies (I2=34.2%; p=0.22). Two studies presented postoperative motor nerve conduction velocities (n=100) with no significant differences (SMD=0.24 in favor of simple decompression, 95%CI: −0.22 to 0.57, p=0.23; I2=0%; p=0.9).

Conclusions: The results of this meta-analysis suggests that there is no difference in motor nerve conduction velocities and clinical outcome scores between simple decompression and ulnar nerve transposition for the treatment of moderate to severe ulnar nerve compression at the elbow in patients with no prior trauma or previous surgeries to the affected elbow. Confidence intervals around the points of estimate are narrow probably excluding clinically meaningful differences. Since ulnar nerve transposition is the more invasive of the two procedures, this data supports the use of simple decompression of the ulnar nerve unless a plausible indication for ulnar nerve transposition exists.

Purpose: We evaluated submuscular anterior transposition of the ulnar nerve at the elbow with lengthening of the medial epicondylars as described by Dellon in patients with ulnar nerf deficiency due to compression.

Material and methods: A consecutive series of 30 submuscular tranpositions of the ulnar nerve in 28 patients were performed between 1994 and 1998. Four patients had had a prior procedure (two simple neurolyses, two subcutaneous transpositions). Mean age was 52 years. Preoperative EMB confirmed the diagnosis of ulnar compression at the elbow. All patients has sensorial and/or motor deficits. Postoperative immobilisation was maintained for 15 to 20 days.

Results: The patients were reviewed at a mean follow-up of four years two months. There were no cases of paraesthesia. Improved sensorial function was observed in 71% of the cases (normalisation in 50%) with improvement in the Foment sign and grip in 81.5% (normalisation in 48%). Mean elbow extension was −5°, and flexion was 135°. There was not limitation on wrist amplitudes. The thumb finger force on the operated side was 78% to 94% that measured on the healthy side and was a function of the MacGowan grade. The palm-finger force was 80% to 95% of the healthy side. There has been no recurrence at last follow-up.

Conclusion: Submuscular transposition using the Dellon technique in 30 cases of ulnar nerve compression at the elbow in patients with ulnar deficiency provided satisfactory sensorial and motor recovery. The usefulness of lengthening the medial epicondyls lies in removing the tension on the ulnar nerve and the little effect on elbow and wrist mobility. Submuscular transposition is the technique of choice for repeated neurolysis.

Abductor deficiency after THA can result from proximal femoral bone loss, trochanteric avulsion, muscle destruction associated with infection, pseudotumor, ALTR to metal debris, or other causes. Whiteside has described a transfer of the tensor muscle and anterior gluteus maximus to the greater trochanter for treatment of absent abductors after THA. Transposition of the tensor muscle requires raising an anterior soft tissue flap to the lever of the interval between the tensor muscle and sartorius, which is the same interval used in an anterior approach to the hip. The muscle is transected distally and transposed posteriorly to attach to the proximal femur. This can result in soft tissue redundancy between the posterior tensor muscle and anterior gluteus maximus. This interval is separated and the anterior gluteus maximis also attached to the proximal femur. Relatively large unconstrained (36 mm heads) were not found to be effective in controlling dislocation in patients with abductor deficiency. In our practice, 11 patients with abductor deficiency were treated with Whiteside's tensor muscle transfer and an unconstrained large diameter femoral head. The mean pre-operative abductor strength was 2.2 and improved to 3.2 post-operatively. One patient sustained a dislocation four weeks after surgery which was treated with open reduction. All of the other hips have remained stable. The combination of a large head and tensor muscle transposition may be a viable alternative to use of a fully constrained component in patients with deficient abductors after THA

Abductor deficiency after THA can result from proximal femoral bone loss, trochanteric avulsion, muscle destruction associated with infection, pseudotumor, ALTR to metal debris, or other causes. Constrained acetabular components are indicated to control instability after THA with deficient abductors. However, the added implant constraint also results in greater stresses at the modular liner-locking mechanism of the constrained component and bone-implant fixation interface, which can contribute to mechanical failure of the constrained implant or mechanical loosening. Use of large heads has been effective in reducing the rate of dislocation after primary THA. However, relatively large (36mm) heads were not found to be effective in controlling dislocation in patients with abductor deficiency. Dual mobility implants which can provide considerably larger head diameters than 36mm may offer an advantage in improving stability in patients with abductor deficiency. However the utility of these devices in controlling instability after THA with deficient abductors has not been established. Whiteside has described a transfer of the tensor muscle and anterior gluteus maximus to the greater trochanter for treatment of absent abductors after THA. Transposition of the tensor muscle requires raising an anterior soft tissue flap to the lever of the interval between the tensor muscle and sartorius, which is the same interval used in an anterior approach to the hip. The muscle is transected distally and transposed posteriorly to attach to the proximal femur. This can result in soft tissue redundancy between the posterior tensor muscle and anterior gluteus maximus. This interval is separated and the anterior gluteus maximus also attached to the proximal femur. The transposed tensor muscle provides muscle coverage over the greater trochanter, which may be beneficial in controlling lateral hip pain. In our practice, 11 patients were treated with Whiteside's tensor muscle transfer. Six patients had absent abductors, one had an avulsed greater trochanter, and four intact but weak abductors. One patient had a muscle transposition alone, one had an ORIF of the greater trochanter and muscle transposition, two had a muscle transposition and head/liner exchange, three had a muscle transposition and cup revision, two had a femoral revision and liner exchange with muscle transposition, and two had a muscle transposition with both component revision. None of the patients had constrained components. The mean pre-operative abductor strength was 2.2 (0/5 in four patients 3/5 in four patients, and 4/5 in three patients). Pre-operative lateral hip pain was none or mild in two patients, moderate in three, and severe in six patients. Mean post-operative abductor strength was 3.2 (2/5 in four patients, 3/5 in three, 4/5 in two, 5/5 in two patients). Post-operative lateral hip pain was none in five and mild in six patients. One patient sustained a dislocation four weeks after surgery which was treated with open reduction. All of the other hips have remained stable. Treatment of patients with hip instability and abductor deficiency has generally required use of a constrained acetabular component. In our experience, transfer of the tensor muscle and anterior gluteus maximus to the greater trochanter can improve abductor strength by one grade and also reduce lateral hip pain. The combination of a large head and tensor muscle transposition may be a viable alternative to use of a fully constrained component in patients with deficient abductors after THA. However, the need for implant constraint should also be individualised and based on factors such as the viability of the transposed muscle, patient compliance with post-operative activity restrictions, femoral head/neck ratio, and cup position

Purpose of the study: Transposition of the anterior tibial tuberosisty (ATT) is often performed during the treatment of periodic dislocation of the patella. The purpose of this retrospective study was to evaluate the rate of medial femorotibial osteoarthritis and medial patellofemoral osteoarthritis after ATT transfer. Material and method: We reviewed 129 knees in 106 patients who underwent surgery from 1988 to 2004. The patients were reviewed at mean 9 years follow-up, minimum 2 years. Three groups were defined:. isolated descent (n=15),. isolated medial shift (n=19), and. descent and medial shift (n=95). The degree of the medial shift and the descent depended on the distance from the tibial tuberosity to the trochlear notch and the Caton-Deschamps index measured preoperatively. Patients who underwent surgery for chronic anterior laxity and/or meniscal lesions were excluded (n=3). All patients were free of osteoarthritis before surgery. A complete radiographic series was available for 102 knees. Unilateral periodic dislocation of the patella was present in 60 patients whose knee x-rays were obtained bilaterally. Results: All patients in group 2 were free of osteoarthritis. In group 2, the rate of medial femorotibial osteoarthritis was 10.5%; the rate of medial patellofemoral osteoarthritis was 21%. In group 3, the rate of medial femorotibial osteoarthritis was 7% and that of medial patellofemoral osteoarthritis 14%. For patients with unilateral periodic patellar dislocation, only the operated knees exhibited medial patellofemoral osteoarthritis (12%). The rate of medial patellofemoral osteoarthritis was significantly greater for knees with a medial shift of the ATT. The rate of medial femorotibial osteoarthritis was 6.8% for knees with medial shift versus 8.3% for the index knees. There was no significant difference between the medial shift knees and the index knees for medial femorotibial osteoarthritis. Discussion: Biomechanical studies have shown increased stress forces on the medial compartment after medial shift of the ATT. However, these studies were performed with normal knees free of the morphological anomalies generally present in knees exhibiting periodic patellar dislocation (abnormally high tibial tuberosity femoral notch distance, trochlear dysplasia. In our series, regarding the rate of medial femorotibial osteoarthritis, there was no significant difference between the knees which underwent a medial shift of the ATT and healthy knees. Consequently, medial shift of the ATT should be avoided when unnecessary; the morphology of the trochlea (depth, morphology of the medial component) can induce increased medial stress on the patellofemoral joint