While hip arthroscopy utilization continues to increase, capsular management remains a controversial topic. Therefore the purpose of this research was to investigate the biomechanical effect of capsulotomy and capsular repair techniques on hip joint kinematics in varying combinations of sagittal and coronal joint positions. Eight fresh-frozen hemipelvises (4 left, 6 male) were dissected of all overlying soft tissue, with the exception of the hip joint capsule. The femur was potted and attached to a load cell, while the pelvis was secured to a custom-designed fixture allowing static alteration of the flexion/extension arc. Optotrak markers were rigidly attached to the femur and pelvis to track motion of the femoral head with respect to the acetabulum. Following specimen preparation, seven conditions were tested: i) intact, ii) after portal placement (anterolateral and mid-anterior), iii) interportal capsulotomy (IPC) [35 mm in length], iv) IPC repair, v)T-capsulotomy [15 mm longitudinal incision], vi) partial T-repair (vertical limb), vii) full T-repair. All conditions were tested in 15° of extension (−15˚), 0°, 30°, 60° and 90° of flexion. Additionally, all flexion angles were tested in neutral, as well as maximum abduction and adduction, resulting in 15 testing positions. 3Nm internal and external rotation moments were manually applied to the femur via the load cell at each position. Rotational range of motion and joint kinematics were recorded. IPC and T-capsulotomies increased rotational ROM and mediolateral (ML) joint translation in several different joint configurations, most notably from 0–30˚ in neutral abduction/adduction. Complete capsular repair restored near native joint kinematics, with no significant differences between any complete capsular repair groups and the intact state, regardless of joint position. An unrepaired IPC resulted in increased rotational ROM, but no other adverse translational kinematics. However, an unrepaired or partially repaired T-capsulotomy resulted in increased rotational ROM and ML translation. The results of this study show that complete capsular repair following interportal or T-capsulotomy adequately restores rotational ROM and joint translation to near intact levels. Where feasible, complete capsular closure should be performed, especially following T-capsulotomy. However, further clinical evaluation is required to determine if adverse kinematics of an unrepaired capsule are associated with patient reported outcomes

To evaluate the impact of routine capsular repair on patient-reported outcomes, survivorship and achievability of clinically important improvement, minimum 5-years post-surgery. Our prospective institutional registry was reviewed for cases undergoing primary HA for FAI, and stratified into two groups depending on whether the capsule was repaired or not. Routine repair was introduced in late 2013. The No Repair group consisted of patients undergoing HA between Jan 2010-June 2013 while the Repair group consisted of patients undergoing HA between Jan 2015-Sept 2018. Exclusion criteria consisted of >50 years, Tonnis>1, dysplasia(LCEA<25), concomitant hip pathologies. PROMs consisted of mHHS, SF36 and UCLA. Metrics of clinically important improvement was evaluated using MCID and SCB. Rates of repeat HA or THA conversion were recorded. 985 cases were included (359 No Repair; 626 Repair), 86% male, average age 27.4±6.7years. Significant improvement in all PROMs at minimum 5-years was observed for both groups (p<0.001 for all; large effect sizes for mHHS and SF36, medium effect sizes for UCLA). At 5-years post-op there was no significant difference between groups for mHHS(p=0.078) or UCLA(0.794). SF36 was significantly poorer for those cases undergoing routine repair(p<0.001) however effect size was small (0.20). Thresholds of MCID and SCB were calculated as 69% and 86% for mHHS, 64% and 77% for UCLA, 43% and 60% for SF36. Both groups achieved MCID and SCB at similar rates for mHHS and UCLA. A significantly lower proportion of cases in the repair groups achieved MCID for SF36 (53.6% vs 63.5%, p=0.034) and SCB for SF36 (37.3% vs 52.8%, p<0.001). No significant difference between groups for THA conversion (0.6% No Repair vs 0.5% Repair) or repeat HA (9.7% No Repair vs 8.1% Repair). Routinely repairing the capsule following HA for FAI demonstrates no clinical benefit over not repairing the capsule 5 years post-surgery

We wish to report the use of a modified ‘Y-V’ medial capsular repair in association with Chevron osteotomy fixed rigidly with Barouk screw for Hallux valgus in 45 patients (52 feet) aged 16 to 70 years (mean 47 years) between July 2004 and September 2005. All patients were retrospectively reviewed by questionnaire, physical examination (American Orthopaedic Foot and Ankle Society score) and comparison of preoperative and post operative x rays. Using this technique none of the patients required additional immobilization apart from wool and crepe bandage following surgery. All osteotomies healed without any problem. There was no deep infection reported in this series. There were two superficial infection treated with oral antibiotics. There is no recurrence of deformity so far. At an average of six months follow up American Orthopaedic Foot and Ankle Society score improved significantly. Intermetatarsal (IM) angle and the hallux valgus (HV) angles were also improved considerably. Stabilization of Chevron osteotomy with k wires, plaster of Paris is well known but these techniques have problems of infection and stiffness. Osteotomies carried out without any stabilization has high recurrence rate. Fixation of osteotomy with Barouk screw is a very simple procedure, which not only gives stability and compression to osteotomy but also reduces need for any plaster immobilization thus speed up rehabilitation. This also gives extra confidence to surgeon to allow patient for early weight bearing and mobilization. We also recommend the use of modified ‘Y-V’ medial capsular repair to correct the hallux valgus angle and reduce the meta tarso-phalangeal joint leading to reduction in possibility of recurrence

Hallux valgus is a common condition and surgical correction has remained a challenge. Scarf osteotomy with Akin procedure is well accepted method. Akin procedure gives spurious correction of the distal alignment of big toe. This study was performed to see alternative way to get best correction without additional phalangeal procedure. Senior author used innovative Y-V medial capsulorraphy with standard Scarf osteotomy. This technique allows reduction of MP joint along with correction of pronation deformity and reduction of sesamoids. We report the use of a modified Y-V medial capsular repair in association with Scarf osteotomy for Hallux valgux in 45 patients (55 feet) aged 18 to 76 years (mean 43 years) between October 2004 and December 2005. Clinical follow up was both subjective and objective. Patients were asked about rating of their satisfaction and objective assessment was done in form of AOFAS score. Using this technique none of the patients required an additional proximal phalangeal osteotomy with metatarsal osteotomy. At six months follow up American Orthopaedic Foot and Ankle Society score improved from 46 to 87. Intermetatarsal (IM) angle and the hallux valgus (HV) angle improved from 16° to 9° and from 31° to 16° respectively (p< 0.05). At final follow up 8 patients were very satisfied, 12 were satisfied while 5 were not satisfied. Of the 55 procedures 51 did not develop any complications. Two had superficial infections, treated successfully with oral antibiotics only. Two patients had recurrence, one was treated with Akin and second patient declined surgery as she was not bothered with it. We recommend the use of this modified ‘Y-V’ medial capsular repair to reduce the need for an additional procedure to augment the correction achieved during Scarf osteotomy for hallux valgus. This reduces hallux valgus angle and maintains it

Introduction:. Repair of the arthrotomy is a performed at the end of every total knee arthroplasty (TKA). After the arthrotomy is performed, most surgeons attempt to close the arthrotomy with the medial and lateral edges anatomically approximated. If no landmarks are made prior to performing the arthrotomy however, there is a risk that anatomic approximation may not be obtained. This study looked into the biomechanical changes in stiffness of the knee before and after a medial parapatellar approach repaired with an anatomic, and shifted capsular repair with the medial side of the arthrotomy shifted up or down when repaired to determine if capsular closure may have an effect on the stiffness of the joint. Methods:. Fourteen cadaveric TKA specimens were retrieved through the Medical Education and Research Institute (Memphis TN). For each specimen tested, the skin and muscle tissue was removed, and the femur and tibia were cut transversely 180 mm from the joint center. Specimens were fixed in extension in a custom knee testing platform (Little Rock AR) and subjected to a 10 Nm varus and valgus torque and a 1.5 Nm internal and external rotational torque. The angle at which these moments occurred was recorded, and each test was repeated for 0, 30, 60, and 90 degrees of flexion. After tests were performed on retrieved TKA specimens, a fellowship trained orthopedic surgeon vented the knee capsule by making an incision with a number 10 scalpel blade in a horizontal nature to provide a landmark for anatomic reapproximation. Tests were repeated as before, after which the surgeon performed a standard arthrotomy and repaired it using #0 suture and a neutral alignment. Sutures were cut and the repair was repeated using upward 5 mm shift and downward 5 mm shift of the medial side of the arthrotomy during the repair. All tests were repeated after each repair technique. Any increase or decrease in laxity after capsule repair was referenced to the TKA laxity tested prior to an arthrotomy being performed. Results:. Simply venting the capsule did increase laxity of the TKA in midflexion to varus torque by 3 degrees under the same torque. Otherwise, when the medial limb of the arthrotomy was shifted up during closure by 5 mm, the knee joint tended to be stiffer in flexion compared to the neutral repair measurements under varus torque, while it was closer to the measurements of the neutral or anatomic closure when the medial limb was shifted down during closure. These changes seemed to be seen in flexion more than full extension. Discussion and Conclusion:. Small changes were measured in the stiffness of the joint after venting the capsule and under different degrees of non-anatomic closure. The results stress the fact that the capsule can be measurably tightened during arthrotomy repair and may impact post-operative rehabilitation or range of motion

INTRODUCTION

The capsular releasing sequence is crucial to safely conduct the Direct Anterior Approach for THA on a regular OR table. The release of the anterior capsule is the first step of the releasing sequence and allows for optimal exposure. This can be done by either resecting a part of the anterior capsule or by preserving it. Our zero hypothesis was that clinical outcomes would not be different between both techniques.

This is the first study to determine if closure of the posterior capsule during revision total hip arthroplasty (THA) results in a reduction in the historically high dislocation rate. Seventy-nine consecutive patients undergoing revision THA with a posterolateral approach and closure of the posterior hip capsule were retrospectively reviewed. At a mean follow-up of fifty-seven months (range twenty-four to one hundred and twenty months), there were only two dislocations (2.5%). The historically high dislocation rates with the posterolateral approach in revision THA, can be significantly decreased with posterior capsular closure from approximately 15% to 2.5%.

To determine if closure of the posterior capsule during revision total hip arthroplasty results in a reduction in the historically high dislocation rate.

The dislocation rate after revision THA with a posterior approach can be minimized by repairing the posterior capsule and rotators.

The historically high dislocation rates with the pos-terolateral approach in revision THA, can be significantly decreased with posterior capsular closure from approximately 15% to 2.5%.

A retrospective study was carried out to review seventy-nine consecutive revision THAs. In all cases, the surgery was done by a single surgeon using the posterolateral approach. In every case, the posterior capsule was meticulously repaired at the end of the procedure. All patients had a minimum two- year follow-up and no patients were lost to follow up.

At a mean follow-up of fifty-seven months (range twenty-four to one hundred and twenty months), there were only two dislocations (2.5%). Both dislocations occurred early postoperatively were anterior. One occurred in a high risk case- a proximal femoral replacement with a trochanteric osteotomy, high hip center and skirted head. The other was due to a technical error, with the cup being excessively anteverted. There were no late dislocations or subluxations.

The dislocation rate after revision THA with a posterior approach can be minimized by balancing soft tissues, correct implant alignment and repairing the posterior capsule and rotators.

Introduction: Various surgical methods have been described to manage the problem of recurrent anterior dislocation of the shoulder. Older procedures Putti-Platt’s, Magnuson-Stack’s or Bristow;’s and Boytchev’s repair are not used today due to a high percentage of failure of 7%–17% incidence of recurrence associated with limited ROM. However, in the last decade the goal of treatment has changed. It is directed now towards restoration of normal function with full ROM of the affected shoulder, based mainly on arthroscopic stabilization or on “open” Neer’s capsular shift procedures combined with Bankart’s repair. However, during the last few years there are more and more papers dealing with a surprising unexpected high number of patients with shoulder instability following arthroscopic repair. The purpose of this study is to review the long term results of “open” Neer’s capsular shift procedure

Materials & Methods: This is a presentation of 87 (78M; 9F) consecutive patients, 19 to 47 year old (mean 23 Y) with a length of follow-up of 4Y–15Y (mean 6Y). 45 of them with traumatic recurrent anterior dislocation of the shoulder had a capsular shift procedure according to Rockwood’s modification. In 42 other patients that had a multidirectional instability with proved dislocations of the affected shoulder a Protzman’s modified capsular shift procedure was used.

Results: 82/87 patients had a stable shoulder without recurrent dislocation. 3 patients had an episode of traumatic shoulder dislocation within 2 months following operation. Two other patients of 42 with multidirectional instability had a recurrence of traumatic dislocation. One patient developed partial brachial plexus injury, most probably due to traction of the affected limb following operation. 78/87 had at follow-up normal shoulder function with full ROM, and the remaining 9 patients had only a slight limitation in shoulder abduction and in external rotation.

Conclusions: Based on this study, it is suggested that capsular shift procedure is an excellent method for repair of recurrent anterior shoulder dislocation, preferable to the “older” procedures, and allows restoration of shoulder stability with better functional results. This is suitable mainly for patients with structural hyperlaxity and multidirectional instability, whereas arthroscopic stabilization might be used in patients with true traumatic instability.

Insufficiency of the lateral collateral ligamentous complex causes posterolateral rotatory instability (PLRI). During reconstruction surgery the joint capsule is repaired, but its biomechanical influence on elbow stability has not been described. We hypothesized that capsular repair reduces ROM and varus angle after reconstruction of the lateral collateral complex. Six fresh frozen cadaveric elbow specimens were used. Varus laxity in supination, pronation and neutral forearm rotation with 1 Nm load and forearm rotaitonal range of motion (ROM) with 0.3 Nm torque were measured using a Microscribe 3DLX digitizing system (Revware Inc, Raleigh, NC). Each specimen was tested under four different conditions: Intact, Complete Tear with LUCL, RCL and capsule tear, LUCL/RCL reconstruction + capsule repair and LUCL/RCL reconstruction only. Reconstruction was performed according to the docking technique (Jones, JSES, 2013) and the capsule was repaired with mattress sutures. Each condition was tested in 30°, 60° and 90° elbow flexion. A two-way ANOVA with Tukey's post-hoc test was used to detect statistical differences between the conditions. Total ROM of the forearm significantly increased in all flexion angles from intact to Complete tear (p<0.001). ROM was restored to normal in 30° and 60° elbow flexion in both reconstruction conditions (p>0.05). LUCL/RCL Reconstruction + capsule repair in 90° elbow flexion was associated with a significantly lower ROM compared to intact (p=0.0003) and reconstruction without capsule repair (p=0.015). Varus angle increased significantly from intact to complete tear (p<0.0001) and restored to normal in both reconstruction conditions (p>0.05) in 30° and 60° elbow flexion. In contrast varus angle was significantly lower in 90° elbow flexion in both reconstruction conditions compared to intact (both p<0.0001). Reconstruction of the lateral collateral complex restores elbow stability, ROM and varus laxity independent of capsular repair. Over tightening of the elbow joint occurred in 90° elbow flexion, which was aggravated by capsular repair. Over all capsular repair can be performed without negatively affecting elbow joint mobility

The Latarjet procedure is a well described method to stabilize anterior shoulder instability. There are concerns of high complication rates, one of these being a painful shoulder without instability due to screw irritation. The arthroscopic changes in the shoulder at time of screw removal compared to those pre-Latarjet have not been described in the literature. We conducted a retrospective review of arthroscopic videos between 2015 and 2022 of 17 patients at the time of their Latarjet screw removal and where available (n=13) compared them to arthroscopic findings at time of index Latarjet. Instability was an exclusion criterion. X-rays prior to screw removal were assessed independently by two observers blinded to patient details for lysis of the graft. Arthroscopic assessment of the anatomy and pathological changes were made by two shoulder surgeons via mutual consensus. An intraclass correlation coefficient (ICC) was analyzed as a measure for the inter-observer reliability for the radiographs. Our cohort had an average age of 21.5±7.7 years and an average period of 16.2±13.1 months between pre- and post-arthroscopy. At screw removal all patients had an inflamed subscapularis muscle with 88% associated musculotendinous tears and 59% had a pathological posterior labrum. Worsening in the condition of subscapularis muscle (93%), humeral (31%) and glenoid (31%) cartilage was found when compared to pre-Latarjet arthroscopes. Three failures of capsular repair were seen, two of these when only one anchor was used. X-ray review demonstrated 79% of patients had graft lysis. Excellent inter-rater reliability was observed with an ICC value of 0.82. Our results show a high rate of pathological change in the subscapularis muscle, glenoid labrum and articular cartilage in the stable but painful Latarjet. 79% of patients had graft lysis with prominent screws on X-ray

Surgical management of cam-type femoroacetabular impingement (FAI) aims to preserve the native hip, restore joint function, and delay the onset of osteoarthritis. However, it is unclear how surgery affects joint mechanics and hip joint stability. The aim was to examine the contributions of each surgical stage (i.e., intact cam hip, capsulotomy, cam resection, capsular repair) towards hip joint centre of rotation and microinstability. Twelve fresh, frozen cadaveric hips (n = 12 males, age = 44 ± 9 years, BMI = 23 ± 3 kg/m2) were skeletonized to the capsule and included in this study. All hips indicated cam morphology on CT data (axial α = 63 ± 6°, radial α = 74 ± 4°) and were mounted onto a six-DOF industrial robot (TX90, Stäubli). The robot positioned each hip in four sagittal angles: 1) Extension, 2) Neutral 0°, 3) Flexion 30°, and 4) Flexion 90°, and performed internal and external hip rotations until a 5-Nm torque was reached in each direction, while recording the hip joint centre's neutral path of translation. After the (i) intact hip was tested, each hip underwent a series of surgical stages and was retested after each stage: (ii) T-capsulotomy (incised lateral iliofemoral capsular ligament), (iii) cam resection (removed morphology), and (iv) capsular repair (sutured portal incisions). Eccentricity of the hip joint centre was quantified by the microinstability index (MI = difference in rotational foci / femoral head radius). Repeated measures ANOVA and post-hoc paired t-tests compared the within-subject differences in hip joint centre and microinstability index, between the testing stages (CI = 95%, SPSS v.24, IBM). At the Extension and Neutral positions, the hip joint centre rotated concentrically after each surgical stage. At Flexion 30°, the hip joint centre shifted inferolaterally during external rotation after capsulotomy (p = 0.009), while at Flexion 90°, the hip joint centre further shifted inferolaterally during external rotation (p = 0.005) and slightly medially during internal rotation after cam resection, compared to the intact stages. Consequently, microinstability increased after the capsulotomy at Flexion 30° (MI = +0.05, p = 0.003) and substantially after cam resection at Flexion 90° (MI = +0.07, p = 0.007). Capsular repair was able to slightly restrain the rotational centre and decrease microinstability at the Flexion 30° and 90° positions (MI = −0.03 and −0.04, respectively). Hip microinstability occurred at higher amplitudes of flexion, with the cam resection providing more intracapsular volume and further lateralizing the hip joint during external rotation. Removing the cam deformity and impingement with the chondrolabral junction also medialized the hip during internal rotation, which can restore more favourable joint loading mechanics and stability. These findings support the pathomechanics of cam FAI and suggest that iatrogenic microinstability may be due to excessive motions, prior to post-operative restoration of static (capsular) and dynamic (muscle) stability. In efforts to limit microinstability, proper nonsurgical management and rehabilitation are essential, while activities that involve larger amplitudes of hip flexion and external rotation should be avoided immediately after surgery

Introduction and Aims: A number of ‘minimally invasive’ approaches have been described which are essentially a standard approach through a smaller incision: the term ‘mini-incision’ is more appropriate. We describe a new technique that is truly soft-tissue sparing and report our early results. Method: Following Malchau’s principles we performed cadaver studies to familiarise ourselves with the approach before conducting a pilot study. The approach involves a 6–8cm oblique incision over the posterior aspect of the greater trochanter. Care is taken to preserve piriformis and gluteus maximus. Meticulous capsular repair is performed through drill holes into bone at the end of the procedure to reconstruct the posterior envelope. There are no restrictions to mobility post-op. Patients were scored pre-operatively and followed up prospectively. The only special instruments required are two large curved Hohmann retractors and an angled cup introducer. Results: One hundred and one consecutive routine primary total hip replacements were performed via the ‘piriformis-sparing minimally invasive approach’ by a single surgeon. Marked on-table stability was noted in all hips prior to capsular repair. Forty-two percent of patients were male. Mean age was 68.9 years (42–90) and BMI 26 (14–39). Average operation time was 64.1 minutes and anaesthetic time 92.5 minutes. Mean fall in haemoglobin in the first 24 hours was 2.3g/dl. Mean incision length was 7.4cm. Follow-up was a minimum of one year (range 12–29 months). There was a highly statistically significant improvement in WOMAC and SF-36 scores at three and 12 months post-operatively (p< 0.0001). Early medical complications occurred in 12 patients, including two superficial infections, all of which resolved. There were no peri-prosthetic fractures and importantly, no dislocations. There were two re-operations: one revision for cup displacement and one washout for deep infection. Conclusion: We believe that the marked stability that we achieve on-table is only possible by sparing piriformis and careful capsular repair. As with all new procedures however, there is a learning curve for both surgeon and assistant. Preliminary results from our pilot study may be interpreted with guarded optimism

The authors report the use of a modified ‘Y-V’ medial capsular repair in association with Scarf osteotomy for Hallux valgus in 55 patients (62 feet) aged 18 to 61 years (mean 43 years) between July 2004 and July 2005. All patients were followed up for minimum 6 months by questionnaire, physical examination (American Orthopaedic Foot and Ankle Society score) and comparison of preoperative and post operative x rays. Using this technique none of the patients required an additional proximal phalangeal osteotomy (Akin Oste-otomy). At six months follow up American Orthopaedic Foot and Ankle Society score improved from 46 to 87. Intermetatarsal (IM) angle and the hallux valgus (HV) angle improved from 16 degree to 9 degree and from 31 degree to 16 degrees respectively (p less than 0.05). Of the sixty two procedures 59 did not develop any complications. Two had superficial infections which required oral antibiotics only. One partial loss of correction of hallux valgus occurred for which the patient refused a second operation. Seven cases had some residual pronation deformity of the big toe identified by the patients who felt the deformity was ‘about 50%’ compared to before the operation. Akins osteotomy achieves an apparent correction of hallux valgus without addressing subluxation of meta-tarso-phalangeal joint. Our technique reduces the meta-tarso-phalangeal joint and corrects the hallux valgus angle anatomically. We recommend the use of this modified ‘Y-V’ medial capsular repair to correct the hallux valgus angle and reduce the need for an additional procedure to augment the correction achieved during Scarf osteotomy for hallux valgus

The hip's capsular ligaments (CL) passively restrain extreme range of motion (ROM) by wrapping around the native femoral head/neck, and protect against impingement and instability. We compared how CL function was affected by device (hip resurfacing arthroplasty, HRA; dual mobility total hip arthroplasty, DM-THA; and conventional THA, C-THA), and surgical approach (anterior and posterior), with and without CL surgical-repair. We hypothesized that CL function would only be preserved when native head-size (HRA/DM-THA) was restored. CL function was quantified on sixteen cadaveric hips, by measuring ROM by internally (IR) and externally rotating (ER) the hip in six functional positions, ranging from full extension with abduction to full flexion with adduction (squatting). Native ROM was compared to ROM after posterior capsulotomy (right hips) or anterior capsulotomy (left hips), and HRA, and C-THA and DM-THA, before and after CL repair. Independent of approach, ROM increased most following C-THA (max 62°), then DM-THA (max 40°), then HRA (max 19°), indicating later CL engagement and reduced biomechanical function with smaller head-size. Dislocations also occurred in squatting after C-THA and DM-THA. CL-repair following HRA restored ROM to the native hip (max 8°). CL-repair following DM-THA reduced ROM hypermobility in flexed positions only and prevented dislocation (max 36°). CL-repair following C-THA did not reduce ROM or prevent dislocation. For HRA and repair, native anatomy was preserved and ligament function was restored. For DM-THA with repair, ligament function depended on the movement of the mobile-bearing, with increased ROM in positions when ligaments could not wrap around head/neck. For C-THA, the reduced head-size resulted in inferior capsular mechanics in all positions as the ligaments remained slack, irrespective of repair. Choosing devices with anatomic head-sizes (HRA/DM-THA) with capsular repair may have greater effect than surgical approach to protect against instability in the early postoperative period

Patients with neuromuscular disease and imbalance present a particularly challenging clinical situation for the orthopaedic hip surgeon. The cause of the neuromuscular imbalance may be intrinsic or extrinsic. Intrinsic disorders include those in which the hip is in development, such as cerebral palsy, polio, CVA, and other spinal cord injuries and disease. This can result in subluxation and dislocation of the hip in growing children, and subsequent pain, and difficulty in sitting and perineal care. Extrinsic factors involve previously stable hips and play a secondary role in the development of osteoarthritis and contractures in later life. Examples of extrinsic factors are Parkinson's disease, dyskinesis, athetosis, and multiple sclerosis. Goals of treatment in adults with pain and dysfunction in the setting of neuromuscular imbalance are to treat contractures and to perform salvage procedures to improve function and eliminate pain. Treatment of patients with neuromuscular imbalance may include resection arthroplasty (Girdlestone), arthrodesis, or total hip arthroplasty. Resection arthroplasty is typically reserved for patients that are non-ambulatory, or hips that are felt to be so unstable that arthroplasty would definitely fail due to instability. In modern times arthrodesis has limited use as it negatively impacts function and self-care in patients with neuromuscular disorders. Total hip arthroplasty has the ability to treat pain, relieve contractures, and provide improved function. Due to the increased risk of instability, special considerations must be made during primary total hip arthroplasty in this patient cohort. Risk of instability may be addressed by surgical approach, head size, or use of alternative bearing constructs. Posterior approach may have increased risk of posterior dislocation in this patient group, particularly if a posterior capsular repair is not possible due to the flexion contractures and sitting position in many patients. Surgeons familiar with the approaches may utilise the anterolateral or direct anterior approach judicially. Release of the adductors may be performed in conjunction with primary total hip arthroplasty to help with post-operative range of motion and to decrease risk of instability. In a standard bearing, the selected head size should be the largest that can be utilised for the particular cup size. Rigorous testing of intra-operative impingement, component rotation, and instability is required. If instability cannot be adequately addressed by a standard bearing, the next option is a dual mobility bearing. Multiple studies have shown improved stability with the use of these bearings, but they are also at risk for instability, intraprosthetic dislocation, and fretting and corrosion of the modular connections. Another option is a constrained liner. However, this results in reduced range of motion, and an increased risk for mechanical complications of the construct. The use of a constrained liner in a primary situation should be limited to the most severe instability cases, and the patient should be counseled with the associated risks. If total hip arthroplasty results in repeated instability, revision surgery or Girdlestone arthroplasty may be considered

Mini-posterior technique advantages: Familiar anatomy; Widely applicable; Predictable (and thus preventable) sources of errors; Demonstrated functional advantages over the 2-incision THA in recent prospective randomised trials and in direct comparison studies. Familiar anatomy: A substantial number of surgeons routinely use the posterior approach; With careful attention to skin incision placement and leg positioning intraoperatively it is relatively easy for most surgeons to shorten the skin incision; With the addition of specialised retractors, offset reamers and offset cup and stem inserters many THA can be done with a skin incision of 10cm or less; Easily converted to standard posterior approach if intraoperative concerns arise; Formal posterior capsular repair substantially lowers historical risk of dislocation. Widely applicable: With relatively little variation this approach can be used for a broad range of THA patients; Several variations of the mini-posterior technique exist (Sculco, Dorr, Swanson, Goldstein); Dorr technique has been used in my practice and we have studied it extensively in direct comparison studies against the 2-incision technique

Polyethylene and femoral head exchange for wear or osteolysis is a common operation. The difficulty lies in the facts that wear and osteolysis are difficult to measure, wear does not always correlate with osteolysis, catastrophic failure (wear through, loosening, or fracture) is difficult to predict, and these problems are usually asymptomatic. I currently recommend this procedure when complete wear through of the polyethylene is present or impending, when the patient has obvious wear and symptoms, or if there is a rapidly enlarging osteolytic lesion. The surgical goals focus on management of debris generation and management of the osteolytic lesion. A third goal becomes avoidance of the know complications of this procedure. Management of debris generation basically involves modernising the head and polyethylene. Management of the osteolytic lesion includes debridement and when possible grafting. By far the most common complication after this procedure is dislocation. Prevention of dislocation should be accomplished by patient education, use of larger heads when possible, and capsular repair. Prerequisites to perform this procedure are a replacement liner of adequate thickness that can be locked or cemented in place. The acetabular component must be stable. Lastly the component must be properly oriented to minimise both wear and dislocation. Metal-on-metal liner conversion to metal-on-poly is becoming more common. Since patient satisfaction with THA is high, MoM patients may unknowingly minimise their symptoms because they are minor compared to the symptoms before surgery. The patient history should include specific questions about groin pain, swelling, hip noise, and asking the patient if they notice their hip on a daily basis. Patient symptoms, osteolysis and a pseudotumor are indications for modular conversion. Radiographically stable, well-oriented components that can accept a polyethylene liner are requirements for a successful conversion

Introduction In an attempt to decrease the incidence of posterior hip dislocation following a posterior approach, a simple capsulorrhaphy was utilized in 255 consecutive primary total hip arthroplasties performed by one surgeon. Methods All patients were reviewed at a minimum of two years post-operatively and no patient was lost to follow-up. One patient sustained a posterior hip dislocation, while there were no anterior hip dislocations. The dislocation rate of 0.39 is equal to or less than the rates of dislocation reported in the literature using a direct lateral approach. Conclusions We postulate that this capsular repair creates not only a static restraint but also a capsule and gluteus medius mediated proprioceptive feedback to guard against extremes of internal rotation of the hip

Polyethylene and femoral head exchange for wear or osteolysis is a common operation. The difficulty lies in the facts that wear and osteolysis are difficult to measure, wear does not always correlate with osteolysis, catastrophic failure (wear through, loosening, or fracture) is difficult to predict, and these problems are usually asymptomatic. I currently recommend this procedure when complete wear through of the polyethylene is present or impending, when the patient has obvious wear and symptoms, or if there is a rapidly enlarging osteolytic lesion. The surgical goals focus on management of debris generation and management of the osteolytic lesion. A third goal becomes avoidance of the know complications of this procedure. Management of debris generation basically involves modernising the head and polyethylene. Management of the osteolytic lesion includes debridement and when possible grafting. By far the most common complication after this procedure is dislocation. Prevention of dislocation should be accomplished by patient education, use of larger heads when possible, and capsular repair. Prerequisites to perform this procedure are a replacement liner of adequate thickness that can be locked or cemented in place. The acetabular component must be stable. Lastly the component must be properly oriented to minimise both wear and dislocation. Metal-on-metal liner exchanges. Metal-on-metal liner conversion to metal-on-poly is becoming more common. Since patient satisfaction with THA is high, MoM patients may unknowingly minimise their symptoms because they are minor compared to the symptoms before surgery. The patient history should include specific questions about groin pain, swelling, hip noise, and asking the patient if they notice their hip on a daily basis. Patient symptoms, osteolysis and a pseudotumour are indications for modular conversion. Radiographically stable, well-oriented components that can accept a polyethylene liner are requirements for a successful conversion

The incidence of first metatarsophalangeal joint (MTPJ) stiffness following bunion surgery varies in the literature from 2% to 60%. The causes include pre-existing degenerative joint disease, infection, chronic regional pain syndrome (Type 1), joint incongruence and avascular necrosis. The aim of this study was to establish whether closure of the capsule influences the range of motion in the first MTPJ. We performed a cadaveric study using a ‘Y’ shaped medial capsulotomy as our model. A mid-medial approach was performed on ten cadaveric feet, exposing the medial capsule of the 1st MTPJ. The range of motion of the 1st MTPJ was recorded, and a ‘Y’ shaped capsulotomy performed. The capsule was then closed in neutral, full plantar flexion, and full dorsi flexion and the range of motion recorded. When the capsule was closed with the first MTPJ at the limit of plantar flexion there was a mean loss of 13.7° of dorsi-flexion (range 12°–15°, p< 0.01) compared with the pre-capsulotomy range of motion. When the capsule was closed in dorsi-flexion there was a mean loss of 9.3° of plantar flexion (range 0°–20°, p< 0.05). There was no change in range of motion when the capsule was closed in neutral. Capsular closure can influence first MPTJ motion. Care should therefore be taken during capsular repair. Closure in extremes of extension or flexion, as advocated in some techniques such as the Mitchell osteotomy, should be avoided