Purpose: The prospective study conducted by an independent examiner included an overall series of 104 ligamento-plasties using the fascia lata (Jaeger procedure). Material and methods: All procedures were performed by the same operator and outcome was assessed at least 12 months after operation (mean follow-up 27 months). Results and discussion: The IKDC scores were comparable with other series using autotransplants: 39% A, 45% B, 12% C, 4% D. Mean residual laxity differential (KT 2000) was 1.92 mm (−2 to 6 mm) and showed the anatomic efficacy of this technique. Extra-articular reinforcement was determinant in supporting the intra-articular plasty, calibrated at 6 mm diameter, explaining the good score obtained for residual differential laxity in sub-extension: 54% A, 29%B, 3%C. Laxity measured between +2 and +3 mm in 14% of the patients who could not be classed in the IKDC A and B classes. Mixed plasty with the fascia lata neutralised rotation clicks in 90.4% of the cases. The lateral portion of the mixed plasty did not raise any problem for ligamentisation explaining its efficacy and low rate of rotation clicks at last follow-up. All professional athletes in this series and all athletes participating in high-level competitions were able to resume their former sports activity at the same level; for the entire series 67% resumed their former sports activities at the same level. Thirty-eight competition level athletes (n=63, 60%) resumed competition after surgery, 24 (38%) practised leisure sports. The change to leisure sports in these 24 patients was related to the knee plasty in eight. Irreducible knee flexion (+5°) was related to reflex dystrophy in four patients. Eleven patients presented reflex dystrophy; two had mobilisation under general anaesthesia. None of the patients had a painful harvesting site. Among the four cases with lateral decoaptation, two were related to poor dissection of the posterolateral angle without any pre-existing lesion of the peripheral formations. Section of the lateral intermuscular partition allowed complete closure of the fascia lata in all the difficult cases. We had only one case of proximal muscular herniation at the harvesting site

Introduction: Trochanteric bursitis rarely needs surgical treatment. A distal lengthening procedure has been described. Purpose: To analyze the outcomes of two different surgical techniques: proximal and distal lengthening of the fascia lata. Materials and methods: Median instead of average was used for the quantitative variables. Twenty one patients (23 hips) were treated between October 1999 and February 2006. They were divided into two groups and their previous medical and surgical history was collected. The proximal Z-plasty group included 10 hips with a median age of 54 years; median body mass index (BMI) was 28.5 and median time from onset of symptoms till surgery was 36 months. The distal Z-plasty group included 13 hips, median age was 54.6 years; median BMI was 26.3; and evolution till surgery was 18 months. Harris hip score, verbal analog scale for pain (VAS) and a Lickert satisfaction scale were used. Results: In the “proximal group” the Harris hip score improved from 61 to 77.5. VAS improved from 82.5 to 27.5 and as regards the Lickert score 3 hips were very satisfied; three were satisfied; two hardly satisfied; one dissatisfied and one very dissatisfied. Two seromas occurred after surgery. In the “distal group” Harris score improved from 63 to 91. VAS improved from 90 to 10 and the Lickert scale gave 5 very satisfied hips; 4 satisfied; none hardly satisfied; 4 dissatisfied and none was very dissatisfied. There was a seroma after surgery. Conclusion: Despite the low number of cases, distal Z- plasty showed better results than the proximal technique in the treatment of trochanteric bursitis

Introduction and Aims: ‘External’ snapping hip, secondary to a tight thickened portion of the iliotibial band snapping over the greater trochanter is usually treated by Z-plasty. We report experience of managing painful paediatric snapping hips by a novel alternative, proximal TFL release. Method: Patients referred between 1989–2002 with painful snapping hips to the paediatric orthopaedic unit were retrospectively reviewed. Diagnosis was made on the basis of history and physical examination. All the patients had a plain radiograph of the hip and other causes of an audible snap were excluded. Most cases had failed to improve with physiotherapy pre-operatively. Fifteen patients (21 hips) had proximal tensor fascia lata release. All the patients had regular follow-up and were assessed for recurrence and complications. Results: There were two boys and thirteen girls. The mean age at the time of operation was 15 years and minimum post-operative follow-up was six months. Two hips required revision surgery. Eighty-one percent had a pain-free non-snapping hip at the time of discharge. The remainder were pain-free, with a reduced frequency of snapping. Conclusion: For painful snapping hips when conservative methods have failed, proximal release can offer good results with low morbidity in a paediatric population

This study describes a safe endoscopic technique for decompression of trochanteric bursa and presents the results of this procedure. Fifteen patients who had failed non-operative treatment for trochanteric bursitis were treated by endoscopic lengthening of fascia lata (FL) and trochanteric bursectomy. Two patients had also failed open decompressions performed at another institution prior to their endoscopic surgery. All patients took part in questionnaires pre-operatively and at three months and twelve months. A two-portal endoscopic procedure was performed in all subjects. A Cruciate incision was made in the FL hence lengthening it in three dimensions. A trochanteric bursectomy was then performed using a mechanical shaver. No patients were lost to follow up. At last review 14 patients rated their result as excellent and one patient had a fair result. There were no complications. The modified Harris hip score improved from 45 to 60, Non-arthritic hip score improved from 45 to 64 and SF12 score improved from 31 to 34. Endoscopic lengthening of FL and trochanteric bursectomy is a safe and effective procedure in relieving the symptoms of persistent trochanteric bursitis

Objectives. The objective of this study was to determine if the use of fascia lata as a tendon regeneration guide (placed into the tendon canal following harvesting the semitendinosus tendon) would improve the incidence of tissue regeneration and prevent fatty degeneration of the semitendinosus muscle. Materials and Methods. Bilateral semitendinosus tendons were harvested from rabbits using a tendon stripper. On the inducing graft (IG) side, the tendon canal and semitendinosus tibial attachment site were connected by the fascia lata, which was harvested at the same width as the semitendinosus tendon. On the control side, no special procedures were performed. Two groups of six rabbits were killed at post-operative weeks 4 and 8, respectively. In addition, three healthy rabbits were killed to obtain normal tissue. We evaluated the incidence of tendon tissue regeneration, cross-sectional area of the regenerated tendon tissue and proportion of fatty tissue in the semitendinosus muscle. Results. At post-operative week 8, the distal end of the regenerated tissue reached the vicinity of the tibial insertion on the control side in two of six specimens. On the IG side, the regenerated tissue maintained continuity with the tibial insertion in all specimens. The cross-sectional area of the IG side was significantly greater than that of the control side. The proportion of fatty tissue in the semitendinosus muscle on the IG side was comparable with that of the control side, but was significantly greater than that of the normal muscle. Conclusions. Tendon tissue regenerated with the fascia lata graft was thicker than naturally occurring regenerated tissue. However, the proportion of fatty tissue in the semitendinosus muscle was greater than that of normal muscle. Cite this article: K. Tabuchi, T. Soejima, H. Murakami, K. Noguchi, N. Shiba, K. Nagata. Inducement of tissue regeneration of harvested hamstring tendons in a rabbit model. Bone Joint Res 2016;5:247–252. DOI: 10.1302/2046-3758.56.2000585

Introduction. Trochanteric bursitis is described as pain over the lateral side of the hip and thigh. The usual treatment is rest, administration of NSAIDs and injection of local anaesthetic and corticosteroid. Occasionally it is resistant to these measures. Background. Whilst performing an ablation of the trochanteric bursa we noticed that the fascia lata looked particularly tight. Therefore a z-plasty of the fascia lata was performed. Methods. Patients were identified from the senior author's logbook. Retrospective case note review and telephone interview study was performed. All patients who have undergone this procedure between October 2004 and September 2006 are included. They had all failed a regime of 8/52 physiotherapy and NSAID followed by x3 injections 8/52 apart. The visual analogue pain scoring system was used to assess all the patients post-operatively. Complete resolution of pain was seen as an excellent result. A score of 1-2 was regarded as good, and 3 or above as poor. All were followed up in the outpatients until they had returned to normal function. Results. We present 15 patients with a mean follow-up of 14 (4-27) months. Mean age 50 (18-76). 10 were women. All were unilateral. 13 excellent and 2 good results. All returned to normal function. There was 1 superficial infection. No patients had a snapping IT band. Discussion. Trochanteric bursitis is a common condition with an incidence in primary care of as 1.8 patients per 1000 per year. It is more common in females (80%). Trochanteric bursitis is commonly due to repetitive trauma with repetitive irritation of the bursa by the fascia lata during walking. Therefore by elongating the fascia lata slightly you can prevent this repetitive trauma. Conclusion. Z-plasty of the fascia lata is a procedure that can be used for the treatment of intractable trochanteric bursitis

Anterior surgical approaches for total hip arthroplasty (THA) have increased popularity due to expected faster recovery and less pain. However, the direct anterior approach (Heuter approach which has been popularised by Matta) has been associated with a higher rate of early revisions than other approaches due to femoral component loosening and fractures. It is also noted to have a long learning curve and other unique complications like anterior femoral cutaneous and femoral nerve injuries. Most surgeons performing this approach will require the use of an expensive special operating table. An alternative to the direct anterior approach is the anterior-based muscle-sparing approach. It is also known as the modified Watson-Jones approach, anterolateral muscle-sparing approach, minimally invasive anterolateral approach and the Röttinger approach. With this technique, the hip joint is approached through the muscle interval between the tensor fascia lata and the gluteal muscles, as opposed to the direct anterior approach which is between the sartorius and rectus femoris and the tensor fascia lata. This approach places the femoral nerve at less risk for injury. I perform this technique in the lateral decubitus position, but it can also be performed in the supine position. An inexpensive home-made laminated L-shaped board is clamped on end of table allowing the ipsilateral leg to extend, adduct, and externally rotate during the femoral preparation. This approach for THA has been reported to produce excellent results. One study reports a complication rate of 0.6% femoral fracture rate and 0.4% revision rate for femoral stem loosening. In a prospective randomised trial looking at the learning curve with new approach, the anterior-based muscle-sparing anterior approach had lower complications than a direct anterior approach. The complications and mean operative time with this approach are reported to be no different than a direct lateral approach. Since this surgical approach is not through an internervous interval, a concern is that this may result in a permanent functional defect as result of injury to the superior gluteal nerve. At a median follow-up of 9.3 months, a MRI study showed 42% of patients with this approach had fat replacement of the tensor fascia lata, which is thought to be irreversible. The clinical significance remains unclear, and inconsequential in my experience. A comparison MRI study showed that there was more damage and atrophy to the gluteus medius muscle with a direct lateral approach at 3 and 12 months. My anecdotal experience is that there is faster recovery and less early pain with this approach. A study of the first 57 patients I performed showed significantly less pain and faster recovery in the first six weeks in patients performed with the anterior-based muscle-sparing approach when compared to a matched cohort of THA patients performed with a direct lateral approach. From 2004 to 2017, I have performed 1308 total hip replacements with the anterior-based muscle sparing approach. Alternatively, I will use the direct lateral approach for patients with stiff hips with significant flexion and/or external rotation contractures where I anticipate difficulty with femoral exposure, osteoporotic femurs due to increased risk of intraoperative trochanteric fractures, previously operated hips with scarring or retained hardware, and Crowe III-IV dysplastic hips when there may be a need for a femoral shortening or derotational osteotomy. Complications have been very infrequent. This approach is a viable alternative to the direct anterior approach for patients desiring a fast recovery. The anterior-based muscle-sparing approach is the approach that I currently use for all outpatient total hip surgeries

Periosteal mesenchymal stem cells (PMSC) are an emerging niche of stem cells to enhance bone healing by tissue engineering process. They have to be differentiated into osteoprogenitors in order to synthesize new bone matrix. In vitro differentiation with specific differentiation medium (DM) is not exactly representative of what occurs in vivo. The interaction between PMSC and growth factors (GF) present in biological matrix is somewhat less understood. The goal of this study is to explore the possibility of spontaneous PMSC differentiation in contact with different biological matrices without DM. 500.000 porcine PMSC were seeded on 6-well plates and cultured with proliferation medium (PM). When reaching 80% confluence, biological samples (n=3) of demineralized bone matrix (DBM), decellularized porcine bone allograft (AOp), human bone allograft (AOh), human periosteum (HP) and human fascia lata (HFL) were added. Negative and positive control wells included cells with only PM or DM, respectively. The differentiation progress was assessed by Alizarin Red staining at days 7, 14 and 21. Bone morphogenetic protein content (BMP 2, 4, 5, 6, 7, 8, 9 and 11) of each sample was also investigated by western blot. Alizarin red highlighted bone nodules neoformation on wells containing AOp, AOh and DBM, like positive controls. HP and HFL wells did not show any nodules. These results are correlated to a global higher BMP expression profile in AOp than in HP and HFL but not statistically significant (p=0.38 and p>.99, respectively). The highest expression in each tissue was that of BMP2 and BMP7, which play an important role in osteoinduction. PMSC are well known to participate to bone formation but, despite BMP presence in HP and HFL, they did not permit to achieve osteogenesis alone. The bone contact seems to be essential to induce in vitro differentiation into osteoprogenitors

Patients demonstrate distinct trajectories of recovery after THA. The purpose of this study was to assess the impact of adjacent muscle quality on postoperative hip kinematics. We hypothesized that patients with better adjacent muscle quality (less fatty infiltration) would have greater early biomechanical improvement. Adults undergoing primary THA were recruited. Preoperative MRI was obtained and evaluated via Scoring Hip Osteoarthritis with MRI Scores (SHOMRI, Lee, 2015). Muscle quality was assessed by measuring fat fraction [FF] from water-fat sequences. Biomechanics were assessed preoperatively and six weeks postoperatively during a staggered stance sit-to-stand using the Kinematic Deviation Index (KDI, Halvorson, 2022). Spearman's rho was used to assess correlations between muscle quality and function. Ten adults (5M, 5F) were recruited (average age: 60.1, BMI: 23.79, SHOMRI: 40.6, KDI: 2.96). Nine underwent a direct anterior approach and one a posterior approach. Preoperatively, better biomechanical function was very strongly correlated with lower medius FF (rho=0.89), strongly correlated with lower FF in the minimus (rho=0.75) and tensor fascia lata (TFL) FF (rho=0.70), and weakly correlated with SHOMRI (rho=0.29). At six weeks, greater biomechanical improvement was strongly correlated with lower minimus FF (rho=0.63), moderately correlated with medius FF (rho=0.59), and weakly correlated with TFL FF (rho=0.26) and SHOMRI (rho=0.39). Lastly, medius FF was moderately correlated with SHOMRI (rho=0.42) with negligible correlations between SHOMRI and FF in the minimus and TFL. These findings suggest adjacent muscle quality may be related to postoperative function following THA, explaining some of the variability and supporting specialized muscle rehabilitation or regeneration therapy to improve outcomes

Introduction. In tissue engineering, the establishment of sufficient vascularization is essential for tissue viability and functionality. Inadequate vascularization disrupts nutrients and oxygen supply. Nonetheless, regenerating intricate vascular networks represents a significant challenge. Consequently, research efforts devoted to preserving and regenerating functional vascular networks in engineered tissues are of paramount importance. The present work aims to validate a decellularisation process with preservation of the vascular network and extracellular matrix (ECM) components in fasciocutaneous flaps. Method. Five vascularized fasciocutaneous flaps from cadaveric donors were carefully harvested from the anterolateral thigh (ALT), preserving the main perforator of the fascia lata. The entire ALT flap underwent decellularization by perfusion using a clinically validated chemical protocol. Fluoroscopy and computed tomography (CT) were used to analyze the persistence of the vascular network within the flap, pre- and post-decellularization. Histological analysis, including hematoxylin and eosin staining, and quantitative DNA assessment evaluated decellularization efficacy. Further qualitative (immunohistochemistry, IHC) and quantitative analyses were conducted to assess the preservation of ECM components, such as collagen, glycosaminoglycans, and elastin. Result. On average, the ALT flap maintains 82% of the perfusion area (p = 0.094) post-treatment. Histological analysis confirmed decellularization efficacy and revealed structural rearrangement. Paired analysis revealed a significant decrease in DNA levels (<14.8 ng/mg of dry weight, p****< 0.0001) and well-maintained ECM. IHC indicated the persistence of elastine, collagen IV and laminin. Quantitative analysis confirmed elastin (p = 0.44) and collagen persistence (+74%, p*** = 0.001, albeit with a decrease in matrix glycosaminoglycans (-41%, p*** = 0.01). Conclusion. Decellularization effectively removed cells, while preserving the ECM overall and maintaining some vascular network integrity. Yet, further study is needed to validate these findings, involving microCT examination of the vascular network and its ability to support cell colonization and viability

Decellularization techniques have advanced to reduce the risk of immune rejection in transplantation. Validation of these protocols typically relies on Crapo's criteria. 1. , which include the absence of visible nuclei and low DNA content. In our study, five decellularization protocols were compared to determine the optimal approach for human fascia lata (HFL) samples. However, our findings raised questions as to why recipients can still develop immunity despite meeting validation criteria. HFL samples were decellularized using four protocols with SDS-Triton X100-DNase (D1 to D4-HFL) and one protocol using solvent-detergent-based baths (D5-HFL). The decellularized samples (D-HFL) were compared to native samples (N-HFL) using histology, and DNA content was measured. The human leukocyte antigen (HLA) content within the matrix was assessed using western blot analysis. Both D-HFL and N-HFL samples, along with negative control patches, were implanted in the backs of 28 Wistar rats. Anti-human IgG serum levels were evaluated after one month. H&E and Hoechst staining revealed the absence of residual cells in all decellularization protocols. DNA content was consistently below the critical threshold (p<0.05). All implanted D-HFL samples resulted in significantly lower anti-human IgG levels compared to N-HFL (p<0.01). However, 2.5 out of 4 rats developed immunity after being implanted with D1 to D4-HFL, with varying levels of anti-human IgG. Only rats implanted with D5-HFL showed undetectable levels of IgG and were considered non-immunized. Western blot analysis indicated that only D5-HFL had a residual HLA content below 1%. The literature on decellularization has primarily relied on Crapo's criteria, which do not consider the role of HLA mismatch in acute immune rejection. Our results suggest that a residual HLA content below 1% should also be considered to prevent immunization, even if other validation criteria are met. Further research is needed to evaluate the impact of residual HLA levels on human allotransplantation outcomes

Introduction:. Purpose of mini-invasive hip arthroplasty, is least damage to skin and muscles. Unlike Roettinger modification to Watson-Jones, our approach requires no special table or instruments. Besides, direction of skin incision is perpendicular to interval between glutei and tensor muscles, thus called a Crisscross Approach. Incision is at direction of retractors causing less skin damage; and parallel to femur allowing expansion. No tendon or muscles are severed achieving a true inter-muscular non invasive approach. Unlike anterior approach, femoral circumflex vessels and lateral femoral cutaneous nerve are spared. Material and Methods:. 240 prospective patients underwent mini-invasive crisscross technique since December 2006. A standard non-cemented hip was implanted. Previously disrupted hip muscles patients were excluded. In the operating room, patients were secured in a lateral decubitus position with the pelvis flexed at 20°–30° to allow operated leg to extend beyond the table to be placed in a standard plastic bag. The anterior superior iliac spine (ASIS), the greater trochanter (GT) and its tubercle are identified and marked. A line is drawn between ASIS and GT tubercle representing the interval between the glutei and the tensor fascia lata muscles. Another line representing the skin incision is drawn perpendicular. It may be curved a little toward the femur starting two inches inferior and posterior to ipsilateral ASIS extending distally for 3 inches or more for obese or muscular patients. The Crisscross Approach starts with a skin incision being made as above and through the subcutaneous fat identifying the inter-muscular interval between the glutei and the tensor fascia lata. Sharp dissection is made in the connecting fascia only and blunt dissection is needed to separate the two muscles. A branch of the superior gluteal nerve proximally crossing from the glutei to the tensor fascia lata may be encountered but it should not be disturbed as long as blunt dissection is maintained. Curved retractors are placed one above and the other below the femoral neck exposing the anterior capsule. Incision is made in the capsule and the retractors are re-placed to better expose the femoral neck. The appropriate level of neck is osteotomized and the head is extracted as routine. Acetabulum is further exposed by placing the curved retractors at about mid anterior and mid posterior. The final appropriate cup size and orientation is implanted routinely. Before exposing the femoral canal the deep fascia at the junction of the glutei and the vastus lateralis should be incised (about 2–3 inches). This will tremendously help femoral canal exposure. Then the surgeon is positioned anterior, the patient is made fully paralyzed and the table is tilted 20°–30° posteriorly (away from the surgeon). Hip extended 20°–30°, externally rotated to 80°–90° and adducted with a retractor underneath femoral neck and a curved one on greater trochanter to protect the glutei. Leg is allowed to drop in a bag (posteriorly). Canal finder is helpful to avoid going through the cortex Broaching or reaming and final implant insertion as routine. Posterior capsule need not be disturbed; however, the superior and inferior capsule should be detached from the neck to allow better exposure of the femoral canal. Closure starts with one or two stitches in the remainder of the capsule. Then suture deep fascia at the junction of glutei and vastus lateralis with absorbable suture. Finally, subcutaneous fat and skin are closed as routine. Results:. There was no major neurovascular damage or complications related to this exposure. Follow up to a maximum of 75 months revealed no deep infection and no dislocation or fracture. We undersized three stems at the beginning but that did not require re-operation. Surgery time averaged 15 minutes longer but that was reduced as we gained experience. Cup position was navigated and postoperative CT scan confirmed satisfactory cup and stem position. One case that had an undersized prosthesis settling to about half an inch short which required a 3/8 inch insole for the patient to wear. Rehab goals were met after 4–6 sessions in all patients. Patients were allowed to go home on two crutches in 2–3 days. Full weight bearing was allowed in 2–4 weeks. No limping noted at 3 months follow up. Discussion:. Crisscross approach differs by transecting no tendon or muscles, requiring no special table or instruments with incision parallel to femur facilitating expansion and reducing skin damage resulting in true non-invasive approach

Aim. Reconstruction of composite soft-tissue defects with extensor apparatus deficiency in patients with periprosthetic joint infection (PJI) of the knee is challenging. We present a single-centre multidisciplinary orthoplastic treatment concept based on a retrospective outcome analysis over 20 years. Method. One-hundred sixty-seven patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 49 patients. Of these, seven presented with extensor apparatus deficiency. Results. One patient underwent primary arthrodesis and six patients underwent autologous reconstruction of the extensor apparatus. The principle to reconstruct missing tissue ‘like with like’ was thereby favoured: Two patients with a wide soft-tissue defect received a free anterolateral thigh flap with fascia lata; one patient with a smaller soft-tissue defect received a free sensate, extended lateral arm flap with triceps tendon; and three patients received a pedicled medial sural artery perforator gastrocnemius flap, of which one with Achilles tendon. Despite good functional results 1 year later, long-term follow-up revealed that two patients had to undergo knee arthrodesis because of recurrent infection and one patient was lost to follow-up. In parts, results have been published under doi: 10.7150/jbji.47018. Conclusions. A treatment concept and its rationale, based on a single-centre experience, is presented. It differentiates between various types of soft-tissue defects and shows reconstructive options following the concept to reconstruct ‘like with like’. Despite good results 1 year postoperatively, PJI of the knee with extensor apparatus deficiency remains a dreaded combination with a poor long-term outcome

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

Aim: Assessment of the management of painful paediatric snapping hips by a novel alternative, ie. proximal TFL release. Materials and Methods: A retrospective study was undertaken between 1989 – 2002, reviewing 15 patients (21 hips) who had had proximal tensor fascia lata release. Diagnosis was made on the basis of history and physical examination. All hips were X-rayed and other causes of an audible snap were excluded. Physiotherapy had been attempted in all cases and most had failed to improve pre-operatively. All cases were followed up for a minimum period of 6 months. Results: There were 2 males and 13 females. The mean age of operation was 15 years. 2 hips required a revision procedure. 81% had a pain-free, non-snapping hip at the time of discharge. There was 1 case of numbness in the thigh secondary to damage to the lateral cutaneous nerve of the thigh. No cases had a long-term Trendelenberg limp. Conclusion: It was felt that proximal release of the tensor fascia lata from the pelvis is a good operation for painful, snapping hips with an excellent result in 81%. This has a similar success rate to the Brignall & Stainsby procedure, ie. Z-plasty of the tensor fascialata

We perform the direct approach using a standard radiolucent operative table with extender at the foot, and the assistance of fluoroscopy. The patient is positioned supine with the pubic symphysis aligned at the table break. The anterior superior iliac spine (ASIS) and center of the knee are marked, and a line drawn between. The incision commences proximally from two finger breadths distal and two finger breadths lateral to the ASIS, and extends distally 8–10 cm. Using fluoroscopy, the anterior aspect femoral neck is located. The incision is placed over the lateral aspect of the greater trochanter, which avoids the lateral femoral cutaneous nerve. The tensor fascia lata is identified, which has a distinctive purple hue, and dissected free from the intermuscular septum lateral to the sartorius and the rectus muscles. The deep, investing aponeurosis of the tensor fascia lata is split using a tonsil. Just below lie the lateral circumflex vessels, two veins and one artery, which must be either ligated or cauterised. A retractor is placed superior to the femoral neck over top of the superior hip capsule. A blunt, cobra-type retractor is then placed along the inferior femoral neck, deep to the rectus muscle and the rectus tendon. A sharp retractor is then used to peel the rectus off from the anterior capsule and placed over the anterior rim of the acetabulum. An anterior capsulectomy is performed. A saw blade is positioned for femoral neck resection and confirmed with fluoroscopy. After resection, acetabular retractors are placed, the socket is reamed, the cup is placed, and position confirmed with fluoroscopy. Turning to the femoral side, the surgeon palpates underneath and around the tensor, around the lateral aspect of the femur, proximal to the gluteus maximus tendon, and places a bone hook around the proximal femur. Femoral preparation and stem insertion require maneuvering the table and adjusting the patient position. The table is “jack-knifed” by lowering the foot of the table to approximately 45 degrees and placing the bed into approximately 15 degrees of Trendelenburg. The contralateral well leg is placed on the padded Mayo stand. A table-mounted femur elevator is attached to the bed, requiring a change in surgical gloves, and attached to the traction hook around the proximal femur. Gentle retraction is placed on the femur to tension the capsule. As the capsule is released the femur will begin to come up/out of the wound and into view. With increasing gentle retraction via the table-mounted hook, the femur is elevated. Simultaneously, the operative limb is externally rotated and adducted underneath the non-operative leg in a lazy “figure of 4” position by the assistant. The use of a “broach-only” stem design is preferred as direct straight reaming of the femur is difficult in most cases. Fluoroscopic images are obtained to confirm femoral implant positioning, offset, neck and leg length. A standardised rapid recovery hospitalization and rehabilitation protocol is used in all cases

Introduction. A deficient abductor mechanism leads to significant morbidity and few studies have been published describing methods for reconstruction or repair. This study reports the reconstruction of hip abductor deficiency using human allograft. Methods. All patients were identified as having deficient abductor mechanisms following total hip arthroplasty through radiographic assessment, MRI, clinical examination and intra-operative exploration. All patients underwent hip abductor reconstruction using a variety of human allografts including proximal humeral, tensor fascia lata, quadriceps and patellar tendon. The type of allograft reconstruction used was customized to each patient, all being attached to proximal femur, allograft bone adjacent to host bone, with cerclage wires. If a mid-substance muscle rupture was identified an allograft tendon to host tendon reconstruction was performed. Results. Allograft reconstruction was performed in 15 patients over 18 months. One patient had an abductor deficiency after a primary total hip. All patients had an abductor lurch gait and positive Trendelenburg test preoperatively. Manual muscle strength testing showed significant weakness with a mean MRC grade of 3+/5. Peri-trochanteric pain was cited as a significant complaint in > 80 % of patients. Proximal humeral allografts, with rotator cuff, were used in 8 patients, 5 had tensor fascia lata and the remainder had patella with attached tendon allograft. The majority of patients had a reduction in pain and 8/15 (53%) increased their abductor strength by almost a full grade. A reduced lurch was observed in 10 (66%) patients and one patient re-dislocated after a failed revision for instability. Conclusion. To our knowledge, this is the largest reported series of allograft reconstruction for a deficient abductor mechanism following hip arthroplasty. A viable solution is demonstrated, with promising early results for a difficult problem, utilizing a straightforward technique with low morbidity

Introduction: Movement of the limb during computer aided arthroplasty may cause soft tissue impingement on the reference marker(RM) and consequently alter the spatial relationship between RM and bone with resulting inaccuracies in navigation. The purpose of this study was to investigate the effect of different degrees of soft tissue dissection on the stability of reference markers during limb movement. Methods: The stability of both one- and two-pin RM systems inserted using three different levels of soft-tissue dissection was analysed in relation to a super-stable RM in fresh cadaver lower limbs. The spatial relationship of the two RMs was analysed using the VectorVision. ®. system (BrainLAB, Germany) during multiple repetitions of four predefined limb movements. All tests were done with RMs inserted in both the distal-anterior femur and distal-lateral femur. Results: Analysis of movements of the test RM in relation to the super-stable RM showed that rotations of less than 0.15. o. and translations of less than 0.4mm occurred in most test combinations. The combination that showed the greatest instability was when a stab incision was used to insert a pin in the distal/lateral femur (translation 0.73mm+/−0.05, rotation 0.25. o. +/− 0.05)(p< 0.001). This instability occurred in both single and double pin RMs(p=0.21). Conclusions: RM pins can be placed in the anterior distal femur through simple stab incisions without resulting in significant soft tissue impingement during limb movement. If pins are placed in the lateral distal femur through stab incisions, impingement may occur from the fascia lata. Release of the fascia lata 1cm either side of the pin prevents significant impingement. Wide skin incision is unnecessary in any location

Movement of the limb during computer aided arthroplasty may cause soft tissue impingement on the reference marker(RM) and consequently alter the spatial relationship between RM and bone with resulting inaccuracies in navigation. The purpose of this study was to investigate the effect of different degrees of soft tissue dissection on the stability of reference markers during limb movement. The stability of both one- and two-pin RM systems inserted using three different levels of soft-tissue dissection was analysed in relation to a super-stable RM in fresh cadaver lower limbs. The spatial relationship of the two RMs was analysed using the VectorVision® system (BrainLAB, Germany) during multiple repetitions of four predefined limb movements. All tests were done with RMs inserted in both the distal-anterior femur and distal-lateral femur. Analysis of movements of the test RM in relation to the super-stable RM showed that rotations of less than 0.15o and translations of less than 0.4mm occurred in most test combinations. The combination that showed the greatest instability was when a stab incision was used to insert a pin in the distal/lateral femur (translation 0.73mm+/− 0.05, rotation 0.25o+/− 0.05)(p< 0.001). This instability occurred in both single and double pin RMs(p=0.21). RM pins can be placed in the anterior distal femur through simple stab incisions without resulting in significant soft tissue impingement during limb movement. If pins are placed in the lateral distal femur through stab incisions, impingement may occur from the fascia lata. Release of the fascia lata 1cm either side of the pin prevents significant impingement. Wide skin incision is unnecessary in any location

Purpose: The aim of this work was to evaluate functional and anatomic results of MacIntosh quadriceps plasty reinforced with a free fascia lata transplant used for the treatment of severe anterior laxity of the knee. Material and methods: We considered severe laxity to be defined as a differential greater than 10 mm (manual Lachmann maximum on KT1000) compared with the healthy side and/or an explosive pivot test scored +++ and/or absolute laxity measured at 20 mm. This retrospective series included 108 patients treated between 1995 and 1998 by the same operator (DS). There were 70 men and 38 women, mean age 29±8.7 years (15–52). Average time from trauma to treatment was 38 months (2–324). Among the 98 patients practicing sports, 47 (43.5%) practiced pivot sports with contact and 51 (47.2%) practiced pivot sports without contact. Mean preoperatiove laxity KT1000 was 18±3 mm (13–30) on the diseased side and 5.34±1.9 mm on the healthy side (15 knees excluded due to rupture of the contralateral anterior cruciate ligament). Mean differential laxity was 12.6±2.3 mm (9–21) and in 44 patients (40.8%) the pivot test was scored +++. Only 37 knees (34%) were totally free of meniscal lesions. Outcome was evaluated by an independent operator using the IKDC method. Results: Results were analysed for 71 patients (37 lost to follow-up giving a review rate of 65.8%) with a mean follow-up of 63.4±12.9 months (40–86). Absolute postoperative laxity was 8.9±2.9 mm (2–18) and differential laxity was 2.6±2.3 (−2 to +8) giving a mean gain in laxity of 10 mm. The pivot test was negative in 73.2% of the knees, 22% were scored +, and 4.2% ++. The overall IKDC score was 87.3±9.6 (56–100). 90% of the patients were satisfied or very satisfied with outcome. Furthermore, 80.3% of patients were able to resume their sports activities at the same or higher level. Conclusion: Mixed plasty using the MacIntosh method with lateral reinforcement using the fascia lata enables effective treatment of severe anterior laxity of the knee. Few studies have differentiated laxity according to severity. Prospective randomised studies devoted to patients with very severe laxity are needed to confirm the results of this technique in comparison with isolated plasty of the anterior cruciate ligament without lateral reinforcement