Prevention of joint dislocation after total hip arthroplasty (THA) is important to keep suitable relationships between surgeons and patients. Capsule has an essential role for stability of joint, especially in hip. Reserving a part of capsule in THA can increase stability. We examined the effect of partial capsulotomy in hip joint for prevention of dislocations after THA. In 178 primary THA for osteoarthritis, partial capsulotomy were performed in 92 cases and generous capsulectomy in 86 cases from 1993 to 2001. Age, gender, pre-operative complications of both groups were matched. All THA were performed from a posterior approach, and in case of partial capsulotomy, anterior one third of hip joint capsule was reserved before placing acetabular component. Posterior capsulorrhaphy was not performed. No hip dislocations have been seen in partial capsulotomy cases, and four posterior dislocations following THA were observed in general capsulectomy cases during one to nine year follow up. Soft tissue imbalance of THA is most at risk for dislocation. The present study showed a satisfying result of partial capsulotomy for prevention of THA dislocation. Residual hip joint capsule can increase joint stability and can resist to dislocation after THA in osteoarthritis

The posterior capsule is variously incised and excised during total hip replacement (THR). There is no consensus on the direction of the capsulotomy and the need to repair the posterior capsule. The objective of this study was to determine the orientation of the collagen fibres and nerves in the posterior hip capsule in patients undergoing THR. Specimens from five patients with osteoarthrosis of the hip (with no fixed deformity) were obtained and fixed in 10% neutral buffered formalin. Sutures were placed to mark the head and trochanteric end before excising. A standard posterior approach was used. The samples were examined and reported by a pathologist. Samples were processed overnight in a VIP5 automatic tissue processor and embedded in paraffin wax, preserving the location of the suture sites on embedding. Sections were cut at 5 Ïm and routinely stained with haematoxylin and eosin. The van Gieson stain was used for collagen fibres. Nerve fibres were highlighted using immunohistochemistry for S100 protein and blood vessels using an antibody to CD34. The collagen bundles seen were predominantly parallel to the axis of the specimen. Dispersed within the collagen bundles were small vascular leashes that were parallel with the collagen fibres. The S100 staining revealed that these were neurovascular leashes, with small nerves running alongside the vessels and the collagen. Nerves that separate from the vessels were likely to serve proprioceptive and nociceptive functions. The direction of the capsulotomy during THR by posterior approach has been traditionally perpendicular to the direction of the capsular fibres. However, if possible, capsulotomy along the orientation of the collagen fibres may be advantageous. As this study demonstrates, it will result in less damage to the capsular collagen fibres, blood vessels and nerves resulting in better capsular repair and healing, and better conservation of pro-prioceptive and nociceptive functions

Introduction: When performing a hip resurfacing procedure through the postero-lateral approach, concern has been expressed as to the proximity of the femoral neurovascular bundle during the anterior capsulotomy. We aimed to identify the proximity of the femoral nerve, artery and vein during an anterior capsulotomy. Methods: 5 fresh frozen cadaveric limbs were used. A standard postero-lateral approach was performed. An anterior incision was then made to identify the femoral neurovascular bundle. Measurements were taken prior to hip dislocation. The femoral head was dislocated, capsulotomy scissors were inserted though the posterior incision and positioned to cut the superior and then inferior aspects of the anterior capsule. The distance from the scissors to each of the neurovascular structures were recorded. Measurements were made with the hip in flexion and extension. Results: Prior to dislocation the mean distance from the capsule was 25mm for the femoral nerve, 21mm for the artery and 21mm for the vein. Following dislocation, with the hip in extension the distance during cutting of the antero-superior capsule to the nerve, artery and vein was 31mm. With the hip in a flexed position, the distance from all three neurovascular structures increased by a mean of 5mm. When the scissors were positioned to cut the antero-inferior capsule in extension, the mean distances to the nerve, artery and vein were 31mm, 28mm and 28mm. When the hip was flexed, the distance to the nerve decreased by 2mm. Discussion: Our study suggests that the neurovascular structures are relatively well protected during an anterior capsulotomy performed during hip resurfacing. The procedure may be safer if the capsulotomy is performed with the hip dislocated and the hip in a flexed position while cutting the antero-superior aspect and in an extended position while cutting the antero-inferior aspect

Several design principles were considered paramount when the surgical technique of performing total hip arthroplasty through an incision in the superior capsule without dislocation of the hip joint was developed. These design principles include: Preservation of the abductors; Preservation of the posterior capsule and short external rotators; Preparation of the femur in situ without dislocation of the hip; In-line access to the femoral shaft axis; Ability to perform a trial reduction; Independence from intraoperative imaging; Independence from a traction table; Applicable to at least 99% of THA procedures. Personal experience with more than 1950 THA using the superior capsulotomy technique over a 12-year period has demonstrated several observations: Dislocation rate of 0.15% (3 in 1950); Acute deep infection rate of 0% (0 in 1950); Universal applicability: used in 99.7% of primary THA; Lateral femoral cutaneous nerve palsy incidence: 0/1950; Femoral nerve palsy incidence: 0/1950; Transient peroneal palsy incidence: 2/1950; Length of stay (since 2010): 1.55 days; Discharge to home: 98%; 90-day cost (2/13 to 2/14) compared to other exposures in CMS patients in the same institution: $24,200 vs $30,100; Readmission costs (CMS 2/13 to 2/14) at 90 days: $0. Conclusion: Performing total hip arthroplasty without dislocation and with preservation of the abductors, posterior capsule and short external rotations has proven to have a low dislocation rate, a low infection rate, and wide applicability. CMS 12-month expenditure data documenting ZERO dollars spent on readmission for any reason within 90 days of surgery demonstrates the potential for simultaneously improving incomes and reducing cost, with particular benefit within the CMS BPCI and private bundled payment programs

Introduction. A small medial extension gap (EG) needs posterior soft tissue release to avoid undesirable additional resection of the distal femur in total knee arthroplasty (TKA). However, the effect of this procedure on the EG is not always sufficient because the EG is influenced not only by the posterior soft tissue but also by the medial collateral ligament (MCL). We hypothesize that contracture of the posterior capsule prevents full elongation of the MCL in extension and we investigated the efficacy of posteromedial vertical capsulotomy (PMVC) on the medial EG which separate MCL from the posterior capsule (Fig. 1). Materials and Methods. The PMVC was performed on 128 knees in which the medial extension gap was considered too small. The EG was initially created with a standard femoral distal cut and tibial cut. To estimate the gaps more precisely before flexion gap (FG) adjustment at the final step of the surgery, we performed a 4 mm precut of the posterior femoral condyle and measured the gaps with the patella reduced after setting a precut trial component that had a usual distal part and 4 mm thick posterior part of the femoral component. This situation was the same as after setting the usual femoral trial component by using the measured resection technique with preservation of the posterior cruciate ligament (PCL) (Fig. 2). The semimembranosus tendon was not released in any cases. Results. After the precut trial was set to the femur, the average EG and FG were 5.6 ± 2.0 mm and 10.0 ± 2.0 mm, respectively (mean ±SD). After performing the PMVC, the average increase of the EG and FG were 2.3 ± 1.4 mm and 0.1 ± 0.3 mm, respectively. The EG increase was significantly larger than the FG increase (p < 0.001). Twenty eight knees showed a 1 mm or less increase in the EG; however, 100 knees (78 %) had a 2 mm or greater increase in the EG with little increase in the FG. Initial gap difference (FG – EG) showed a positive corelation with EG increase after PMVC (R = 0.51, p < 0.001) (Fig. 3). Conclusions. To make adequate EG and FG, it is important to understand which soft tissue management is effective to increase the FG or the EG. To increase the FG only, PCL resection is useful. However, the effective methodology of widening the EG without changing the FG is unknown. The EG of the varus knee is influenced by several factors such as tightness of the MCL, the posterior capsule, the semimembranosus tendon and protrusion of the posterior femoral component. In this study, a precut trial component was used to take into account the effect of posterior protrusion of the femoral component and the semimembranosus tendon was not released and we achieved a selective EG increase without changing the FG by the PMVC which allowed the MCL and the posterior capsule to act freely from each other

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

Economic data, clinical outcome studies, and anatomical studies continue to support the Superior Hip Approach as a preferred approach for improved safety, maximal tissue preservation, rapid recovery, and minimised cost.

Clinical studies show exceedingly low rates of all major complications including femur fracture, dislocation, and nerve injury.

Economic data from Q1 2013 to Q2 2016 demonstrate that CMS-insured patients treated by the Superior Hip Approach have the lowest cost of all patients treated in Massachusetts by an average of more than $7,000 over 90 days. The data show that the patients treated by the Superior Hip Approach have lower cost than any other surgical technique.

Matched-pair bioskills dissections demonstrate far better preservation of the hip joint capsule and short external rotators than the anterior approach.

Design principles include: Preservation of the abductors; Preservation of the posterior capsule and short external rotators; Preparation of the femur in situ prior to femoral neck osteotomy; Excision of the femoral head, thereby avoiding surgical dislocation of the hip; In-line access to the femoral shaft axis; Ability to perform a trial reduction; Independence from intra-operative imaging; Independence from a traction table; Applicable to at least 99% of THA procedures.

Merriam Webster - ide•al adjective \ī-′dē(−ə)l, ′ī\: exactly right for a particular purpose, situation, or person

Dictionary.com - 1: conceived as constituting a standard of perfection or excellence; 2: regarded as perfect of its kind; 3: existing only in the imagination; not real or actual

Concepts: Tissue Preserving - anterior and posterior capsule maintained: YES; No dislocation; Minimal leg manipulation; Rapid Rehabilitation: YES; Half the average LOS at NE Baptist; Safe: YES; Fewer complications than standard approach; Transferable and Reproducible ???; Limited adoption; Optimally executed with navigation; Leg length assessment less accessible; Neck cut measured from GT; “Funny looking” impactors/reamers - different “feel”.

IDEAL: For some… but not for most.

Aims. Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck. Methods. A Hueter approach and capsulotomy were performed bilaterally in six cadaveric hips. In the experimental group, a one-third tubular plate was secured to the inferomedial femoral neck at 6:00 on the clockface. The contralateral hip served as a control with surgical approach and capsulotomy without fixation. Pre- and post-contrast MRI was then performed to quantify signal intensity in the femoral head and neck. Qualitative assessment of the terminal arterial branches to the femoral head, specifically the inferior retinacular artery (IRA), was also performed. Results. Quantitative MRI revealed a mean reduction of 1.8% (SD 3.1%) of arterial contribution in the femoral head and a mean reduction of 7.1% (SD 10.6%) in the femoral neck in the plating group compared to non-plated controls. Based on femoral head quadrant analysis, the largest mean decrease in arterial contribution was in the inferomedial quadrant (4.0%, SD 6.6%). No significant differences were found between control and experimental hips for any femoral neck or femoral head regions. The inferior retinaculum of Weitbrecht (containing the IRA) was directly visualized in six of 12 specimens. Qualitative MRI assessment confirmed IRA integrity in all specimens. Conclusion. Calcar femoral neck plating at the 6:00 position on the clockface resulted in minimal decrease in femoral head and neck vascularity, and therefore it may be considered as an adjunct to laterally-based fixation for reduction and fixation of femoral neck fractures, especially in younger patients. Cite this article: Bone Jt Open 2021;2(8):611–617

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

Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and systemic lead poisoning. The literature is sparse on this subject, with mostly sporadic case reports utilizing hip arthroscopy. We report on the largest series of removal of bullets from the hip joints using open surgical. We reviewed prospectively collected data of patients who presented to a single institution with civilian gunshot injuries that breached the hip joint between 01 January 2009 and 31 December 2022. We included all cases where the bullet was retained within the hip joint area. Exclusion criteria: cases where the hip joint was not breached, bullets were not retained around the hip area or cases with isolated acetabulum involvement. One hundred and eighteen (118) patients were identified. One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier. Of the remaining 117 patients, 70 had retained bullets around the hip joint. In 44 patients we undertook bullet removal using the followingsurgical hip dislocation (n = 18), hip arthrotomy (n = 18), removal at site of fracture fixation/replacement (n = 2), posterior wall osteotomy (n = 1), direct removal without capsulotomy (tractotomy) (n = 5). In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove (n=4), patients’ clinical condition did not allow for further surgery (n= 4) and patient refusal (n=1). No patients underwent hip arthroscopy. With adequate pre-operative imaging and surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy; using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation

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

Introduction. The use of less invasive techniques for total hip arthroplasty (THA) has remained controversial with some studies showing a higher incidence of complications. The technique of performing total hip arthroplasty through a superior capsulotomy was developed to maximally preserve the soft tissue envelope surrounding the hip. The current study assesses the recovery and complications of hips replaced using conventional and tissue preserving techniques. Methods. 206 hips in 191 patients with a mean follow-up of 4.3 ± 1.0 (range, 3.2 – 5.9) years underwent total hip arthroplasty using the superior capsulotomy technique. The mean age at operation was 55.7 ± 12.9 (19 – 85) years and the operation was performed for 106 hips (51%) in men. The surgical technique involves exposing the superior hip joint capsule posterior to the medius and minimus, and anterior to the short external rotators. The femur is prepared with the femoral head in place and then the femoral head is excised without dislocation. These 206 hips were compared to a cohort of 279 hips replaced using the transgluteal exposure (control group). These 2 series were controlled for complexity and demographic factors. Recovery was evaluated using the Merle d'Aubigné score at 6 and 12 weeks postoperatively. Results. Two of the 206 hips (1%) replaced using the superior capsulotomy have been revised, one for failure of osseointegration of a nonmodular CoCr acetabular component and one for fracture of a ceramic liner at 21 months. In addition, there were 3 surgical complications. These included one intraoperative and one postoperative nondisplaced trochanteric fracture treated nonoperatively and one anterior hip dislocation. Assessment of the control group demonstrated five revisions: one for recurrent dislocation, two for failure of osseointegration of the femoral component, one for malseating of an acetabular liner, and one for fracture of a ceramic liner. Four hips developed trochanteric wafer nonunions of which 2 required repair. There was one intraoperative trochanteric fracture and two postoperative displaced trochanteric fractures requiring repair. Three hips sustained intraoperative femoral cracks that were cerclaged, and one pelvis sustained a posterior wall fracture that was repaired at surgery. There were two arthrotomies, one for treatement of infection and one for suspected infection. The complication rate was significantly higher in the control group than in the study group. Compared to the control group, the hips replaced using the superior capsulotomy technique had significantly higher hip scores at the 1st and 2nd followup: 1st f/u Merle D'Aubigné score of 15.6 ± 1.6 (9 – 18) vs 13.1 ± 1.8 (8 – 18) and 2nd f/u 17.1 ± 1.1 (13 – 18) vs 16.2 ± 1.6 (10 – 18). Conclusion. These results suggest that the superior capsulotomy technique, with the goal of soft tissue preservation, is a safe and reliable method of performing total hip arthroplasty compared to one conventional THA technique. These results show that the patients recovered quickly and experienced a low incidence of perioperative complications

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

Background. Performing total knee replacement needs both bony & soft tissue consideration. Late John Insall advocating spacer blocks with concept of balanced & equal flexion – extension Gap. Although we usually excise both ACL & PCL, still it is possible to retain more soft tissue. Both PCL retaining & sacrificing Require intact collaterals for stability. Superficial MCL & LCL should be preserved, if possible. After PCL removal the following advantages could obtain: More correction of fixed varus or valgus deformity, More surgical exposure. but there are no proved disadvantages like; increasing in stress & loosening of bone-cement-prosthesis interface, specific clinical difference in ROM, forward lean during stepping up, proprioception inferiority. In other hand over tight PCL cause excessive rollback of tibia & knee hinges open, preventing flexion (booking), and Severe posteromedial poly wear in poor balance PCL might be happened. Mid range laxity when Post. Capsule is tight, even with correct tensioning in full extension & 90 degree flexion, may occur (and secondary collateral ligaments imbalance throughout ROM). There is a major effect of capsular contracture in coronal mal alignment with flexion contracture. Full MCL releases not only correct fixed varus but also open the medial space in flexion. MCL & post. Capsule has combined valgus resistant effect in extension. PCL release increase flexion gap more, May be necessary to release something that affect extension gap as compensated balancing (Post.medial capsule). Any flexion contracture need to posterior capsulotomy & post. Condyle osteophyte removal before femoral recut. So it is possible to perform posteromedial capsulotomy prior to superficial MCL release. Method. From May 2009 to June 2013, 219 TKA (165 patient) (bilateral in 54 patients, simultaneous bilateral in 5 patients) with primary DJD and varus deformity of knees were operated by myself with joint replacement. Most patients had some degree of varus correction in flexion, passively. The varus angle was less than 25*, means mild to severe but not decompensate. 46 patients had some degree of patella baja. For soft tissue balancing during Total knee arthroplasty I consider the following steps; Medial capsule & deep MCL release, PCL release, Posteromedial capsulotomy, semimembranous release, Superficial MCL release, Pes anserinous release. Post.medial capsulotomy was done in all cases. The Average Age was 65.47 years, 131 patients (177 knees) were female (79.3%) and five of them had bilateral TKA simultaneously. Lt Knee was operated in 94 cases (42.9% of 219). Spinal anesthesia was applied in 54.3% (119 patients) & epidural anesthesisa in 5 % (13 cases). 14 knees were operated with MIS technique and 205 knees with Standard medial parapatellar incision. Semi membranous release was necessary in 72 knees (33 pure=15%, without S.MCL release). S.MCL release was mandatory in 39 (17.8 %) knees for checking balanced medial and lateral subtle laxity (playing), I have used simple blade with 1 & 2 mm thickness in each ends for younger patients, and the other one with 3&4 mm thickness in elder cases. Results. Average follow up period is 2.07 years. Average Operating time was 1: 38 (h: m). Average Transfusion = 1.29 unit packed cell. Average varus malalignment=14.76*(2–25*) / Av. Valgus angle= 7.11* (5–10 *) / Av. DLFA= 91.15* (85–102*) / Av. PMTA = 82.04* (68.5–90*) / Av. Ext. rotation cut = 5.7* (0–9). Stage l + PCL + Post. Med. Capsular release was performed in all. pure stage l + P.M.capsular release in147 cases(67.2%), plus semimembrnous release in33 cases(15%), S.MCL release in 39cases(17.8%)/ Av. Post op alignment:1.01 * varus(0 −6 *) (worse in medial pivot knee). so S.MCL release was preventedin 82.1% of cases. Av. Polyethylen size: 12.26 (9 in oxynium −19 in plus) / Semi membranous release was necessary in 72(32.8%) cases (preop varus 17.57*). / S.MCL release was mandatory in 39(17.8 %) cases (preop varus 17.6 * & No Flexibility in 30* flexion). pre operation knee society score: stage I = 26.6, stage II = 38.7 increase to stage I = 86.45, stage II = 77.63. Conclusion. In society with more kneeling habitués, during performing total knee arthroplasty with less than 25* degree varus malalignment plus some degree flexibility of the deformity in flexion, it is wise to consider posteromedial capsular release prior to semi membranous & S.MCL release to obtain full correction of alignment. But the most important thing is reaching to more align limb without instability, regardless of various technique

In perfroming hip resurfacing arthroplasty, concern has been expressed as to the proximity of the femoral neurovascular bundle during the anterior capsulotomy and the risk of damage during this maneuver. We therefore aimed to identify the proximity of the femoral nerve, artery and vein during an anterior capsulotomy done during a hip resurfacing procedure using the posterior approach. A standard posterior approach was performed in 5 fresh frozen cadavic limbs. An anterior incision was then used to measure the distance of the femoral neurovascular structures to the anterior capsule. Measurements from the most posterior aspect of the vessels and nerves to the most anterior aspect of the anterior capsule were taken prior to hip dislocation. The femoral head was then dislocated, and measurements were made with the hip in both flexion and extension. In a separate group of eleven patients that underwent routine MR imaging of the hip, measurements were taken to assess the proximity of the anterior joint capsule to the femoral neurovascular bundle, by a specialist musculoskeletal radiologist who had no prior knowledge of the results obtained during the cadaveric dissection. All 5 cadaveric limbs were utilised. 3 were male and 2 were female. The average age was 72.4 years (range 56–84). The patients whom underwent routine MR imaging incorporated 6 males and 5 females with a mean age of 43.7 years (age range 18–64 years). There was no significant difference between the mean distances to the nerve (p=0.21), artery (p=0.21) or vein (p=0.65) between the MR and cadaveric groups. Prior to dislocation the femoral artery and vein were closest to the anterior capsule (mean distance of 21mm) and the femoral nerve was the furthest away (mean distance 25mm). Following dislocation there was a significant increase (25mm to 31mm) in mean distance to the femoral nerve when the superior capsule was cut with the hip in a flexed position (p=0.01) and to the femoral artery in flexion (increase mean distance from 21mm to 35mm) (p< 0.0001) and in extension(increase mean distance from 21mm to 31mm) (p=0.005). When the inferior capsule was cut, there was a significant increase (25mm to 31mm) in mean distance to the femoral nerve and femoral artery when the hip was dislocated and the capsule cut with the hip in flexion (increase mean distance from 21mm to 27mm) (p=0.019) and in extension(increase mean distance from 21mm to 28mm) (p=0.015). This study suggests that the neurovascular structures are relatively well protected during an anterior capsulotomy performed during hip resurfacing. The procedure may be safer if the capsulotomy is performed with the hip dislocated and the hip in a flexed position while cutting the antero-superior aspect and in an extended position while cutting the antero-inferior aspect

Introduction. The risk of hip dislocation after revision total hip arthroplasty is up to 20% following surgery for periprosthetic fractures. A technique was developed by the senior authors, involving a transtrochanteric osteotomy and superior capsulotomy to attempt to minimise this risk(1). Methods. This prospective study examines a cohort of 40 patients undergoing this novel technique, which involves extending the fracture proximally to the tip of the greater trochanter. This is then extended into the soft tissues in the mid lateral plane as a split of the glutei and a minimally superior capsulotomy (preserving the anterior and posterior capsule). This allows for revision of the femoral component, and retention of the socket and liner. The outcomes of interest to the authors were dislocation rates, clinical outcome measured using the Oxford hip score. These were assessed along with X-ray imaging at 1, 2 and 5-year intervals to confirm fracture union and measure stem subsidence. Results. Patients averaged 80 years of age, with a higher ratio of females (3:2). There were no cases of hip joint dislocations. Two patients (5%) underwent subsequent revision hip arthroplasty within the first 12 months of initial revision. Femoral stem subsidence at 1 year averaged 5.9 mm. All fractures showed radiological evidence of union. The Oxford hip score was fair, averaging 31/48 by 1 year post-op, and then plateaued at 32.8/48 at 2 years post-op. Conclusion. 5 year follow-up of this novel operative technique in revision arthroplasty of Vancouver B periprosthetic hip fractures has confirmed the benefits, with no cases of hip dislocation, along with overall satisfactory patient clinical outcomes

Hammer toe involves metatarsophalangeal joint (MTPJ) hyperextension and proximal interphalangeal joint (PIPJ) flexion. Surgery commonly involves excision arthroplasty or fusion of the PIPJ with MTPJ soft tissue release if necessary. Previous series record that MTPJ release was carried out “as required” but not how often release is necessary. Myerson and Shereff's (1989) cadaver study found release of the extensors, MTPJ capsule and collateral ligaments necessary for full hammertoe correction. Hossain (2002) found the clinical results of this procedure were no better than simple PIPJ fusion. We release the MTPJ if hyperextension persists after PIPJ correction and release the components sequentially. We studied how often and how extensive a release was required, and how this corelated with pre-operative assessment. We reviewed the records of 164 patients who had hammer toe correction under one consultant surgeon. Patients with complex corrections were excluded. The severity of the pre-operative deformity was classified as type 1 (PIPJ and MTPJ correctable), 2 (PIPJ fixed, MTPJ correctable) or 3 (neither joint correctable). We recorded the extent of release required for each toe. Results. Of 334 type 2 toes in 146 patients, 178 (53.3%) required no MTPJ release, 11 (3.3%) extensor tenotomy only, 15 (4.5%) extensor tenotomy and MTPJ dorsal capsulotomy and 130 (38.9%) extensor tenotomy, capsulotomy and collateral ligament release. Of 31 type 3 toes in 18 patients, one (3.2%) needed no release, 2 (6.5%) tenotomy, one (3.2%) capsulotomy and 27 (87.1%) complete release. Discussion. Nearly 50% of toes needed MTP soft tissue release, partial in 8%. Pre-operative assessment was not very accurate in predicting the need for release. We have not yet correlated need for release with clinical outcome. Conclusion. MTP release is required in many hammertoe corrections. Assessment of toe position after incision of each structure may avoid the need for complete release

Introduction:. A surgical hip dislocation provides circumferential access to the femoral head and is essential in the treatment pediatric and adult hip disease. Iatrogenic injury to the femoral head blood supply during a surgical may result in the osteonecrosis of the femoral head. In order to reduce vessel injury and incidence of AVN, the Greater Trochanteric Osteotomy (GTO) was developed and popularized by Ganz. The downside of this approach is the increased morbidity associated with the GTO including non-union in 8% and painful hardware requiring removal in 20% of patients. (reference) Recent studies performed at our institution have mapped the extra-osseous course of the medial femoral circumflex artery and provide surgical guidelines for a vessel preserving posterolateral approach. In this cadaveric model using Gadolinium enhanced MRI, we investigate whether standardized alterations in the postero-lateral surgical approach may reliably preserve femoral head vascularity during a posterior surgical hip dislocation. Methods:. In 8 cadaveric specimens the senior author (ES) performed a surgical hip dislocation through the posterolateral approach with surgical modifications designed to protect the superior and inferior retinacular arteries. In every specimen the same surgical alterations were made using a ruler: the Quadratus Femoris myotomy occurred 2.5 cm off its trochanteric insertion, the piriformis tenotomy occurred at its insertion and extended obliquely leaving a 2 cm cuff of conjoin tendon (inferior gemellus), and the Obturator Externus (OE) was myotomized 2 cm off its trochanteric insertion. (Figure 1) For the capsulotomy, the incision started on the posterior femoral neck directly beneath the cut obturator externus tendon and extending posteriorly to the acetabulum. Superior and inferior extensions of the capsulotomy ran parallel to the acetabular rim creating a T-shaped capsulotomy. After the surgical dislocation was complete, the medial femoral circumflex artery (MFCA) was cannulated and Gadolinium-enhanced MRI performed in order to assess intra-osseous femoral head perfusion and compared to the gadolinium femoral head perfusion of the contra-lateral hip as a non-operative control. Gross-dissection after polyurethane latex injection in the cannulated MFCA was performed to validate MRI findings and to assess for vessel integrity after the surgical dislocation. Results:. In 8 cadaveric specimens MRI quantification of femoral head perfusion was 94.3% and femoral head-neck junction perfusion was 93.5% compared to the non-operative control. (Figure 2) Gross dissection after latex injection into the MFCA demonstrated intact superior and inferior retinacular arteries in all 8 specimens. (Figure 3). Discussion and Conclusions:. In this study, perfusion to the femoral head and head-neck junction is preserved following posterior surgical dislocation through the postero-lateral approach. These preliminary findings suggest that specific surgical modifications can protect and reliably maintain vascularity to the femoral head after surgical hip dislocation. This approach may benefit hip resurfacing and potentially decease risk of femoral neck fracture secondary to osteonecrosis. In addition this may allow a vascular preserving surgical hip dislocation to be performed without the need for a GTO

Background. Performing total knee replacement needs both bony & soft tissue consideration. Late John Insall advocating spacer blocks with concept of balanced & equal flexion – extension Gap. Although we usually excise both ACL & PCL, still it is possible to retain more soft tissue. Both PCL retaining & sacrificing Require intact collaterals for stability. Superficial MCL & LCL should be preserved, if possible. after PCL removal the following advantages could obtain: More correction of fixed varus or valgus deformity, More surgical exposure. but there are no proved disadvantages like; increasing in stress & loosening of bone-cement-prosthesis interface, specific clinical difference in ROM, forward lean during stepping up, proprioception inferiority. in other hand Over tight PCL cause excessive rollback of tibia & knee hinges open, preventing flexion (booking), and Severe posteromedial poly wear in poor balance PCL might be happened. Mid range laxity when Post. Capsule is tight, even with correct tensioning in full extension & 90 degree flexion, may occur (and secondary collateral ligaments imbalance throughout ROM). There is a major effect of capsular contracture in coronal mal alignment with flexion contracture. Full MCL releases not only correct fixed varus but also open the medial space in flexion. MCL & post. Capsule has combined valgus resistant effect in extension. PCL release increase flexion gap more, May be necessary to release something that affect extension gap as compensated balancing (Post.medial capsule). Any flexion contracture need to posterior capsulotomy & post. Condyle osteophyte removal before femoral recut. So it is possible to perform posteromedial capsulotomy prior to superficial MCL release. Method. From May to Dec. 2009, 22 patients (23 knees) with primary DJD and varus deformity of knees were operated by myself with joint replacement. most patients had some degree of varus correction in flexion, passively. the varus angle was less than 25∗, means mild to severe but not decompensated. For soft tissue balancing during Total knee arthroplasty I consider the following steps;. Medial capsule & deep MCL release, PCL release, Posteromedial capsulotomy, semimembranous release, Superficial MCL release, Pes anserinous release. Post. medial capsulotomy was done in all cases. The Average Age was 64.74 years, 19 patients were female (83%) and one of them had bilateral TKA simultaneously. Lt Knee was operated in 14 cases (70% of 24). Spinal anesthesia was applied in 82%. 10 patients were operated with MIS technique and 13 patients with Standard medial parapatellar incision. Semi membranous release was necessary in 4 cases (preop varus 17,20,24,25∗). MCL release was mandatory in 2 cases (preop varus 17, 24 ∗ & No Flexibility in 30∗ flexion).for checking balanced medial and lateral subtle laxity (playing), I have used simple blade with 1 & 2 mm thickness in each ends for younger patients, and the other one with 3&4 mm thickness in elder cases. Results. Average follow up period is 234.45 days. Average Operating time was 1: 32 (h:m). Average Transfusion = 1.22 unit packed cell. No Flexibility in 30∗ flexion was seen in 3 patients. Average varus malalignment =15.29∗ (2-25∗)/Av. Valgus angle = 7.19∗ (5-10 ∗)/Av. DLFA = 90.47∗ (87-93∗)/Av. PMTA = 83.41∗ (77-88.5∗)/Av. Ext. rotation cut = 3.11∗. Stage l + PCL + Post. Med. Capsular release was performed in 82.61%./Av. Post op alignment: 1.8 ∗ varus (0 -6 ∗) (worse in medial pivot knee). Av. Polyethylen size: 12.4 (9 in oxynium -19 in plus)/Semi membranous release was necessary in 4 cases (preop varus 17,20,24,25∗) (Post. Op varus 1,6,4,2)./S.MCL release was mandatory in 2 cases (preop varus 17, 24 ∗ & No Flexibility in 30∗ flexion) (Post. Op varus: 1, 4 ∗). pre operation knee society score: stage I = 27.8, stage II = 37.9 increase to stage I = 85.47, stage II = 75.65. Conclusion. In society with more kneeling habitués, during performing total knee arthroplasty with less than 25∗ degree varus malalignment plus some degree flexibility of the deformity in flexion, it is wise to consider posteromedial capsular release prior to semi membranous & S.MCL release to obtain full correction of alignment. But the most important things is reaching to full align limb regardless of which chosen technique