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

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.

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

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

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

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

The first rule in properly cementing a femoral component is obtaining adequate exposure of the proximal femur. This is achieved reproducibly in anterior approach surgery with anterior and superior capsulotomy, combined with release of the conjoined tendon from the inner trochanter and piriformis tendon retraction, or flip behind the trochanter. This will be demonstrated. The steps of cementation are well established, and not specific to one approach. They involve entry to the proximal femur in a lateral and posterior position, achieving central alignment within the proximal femur with the broach, application of a cement restrictor to a point 1.5 to 2cm distal to the proposed tip of the implant, appropriate preparation of the cancellous bone to receive the cement, applying cement in a sufficiently doughy state to be able to achieve penetration into the cancellous bone, and mechanical pressurization into that cancellous bone. We routinely apply cement directly to the proximal aspect of the femoral component as the cement sticks to the metal, preventing marrow contents generated during the insertion from contacting the metal. In discussing the factors contributing to a dry surgical field, the importance of relative hypotension achieved from regional anesthesia cannot be overstated

Introduction. Early rehabilitation and discharge following minimally-invasive total hip arthroplasty has potential risks including the possibility that patients may become progressively anemic at home. The current study assess the use of pre-emptive autologous blood transfusion on the length of stay, readmission, and allogenous transfusion. Methods. Patients treated by primary total hip arthroplasty using the superior capsulotomy technique were studied. Patients were divided into two groups. Group 1 were patients who did donate autologous blood and received an intra-operative pre-emptive transfusion. There were 283 patients in Group 1. Group 2 were patients who were medically capable of donating autologous blood but did not for non-medical reasons. There were 71 patients in Group 2. Patients who did not donate autologous blood for medical reasons (preoperative Hgb less than 11.5, age over 80) were excluded. All patients received general anesthesia. Length of stay, allogenous transfusion and readmission were compared. Results. The mean length of stay after surgery for the Group 1 patients who received autologous blood donation during primary THA was 1.56 days (SD 78 days, range 0–4). The mean length of stay for the Group 2 patients who did not donate or receive autologous blood during primary THA was 1.87 days (SD 84 days, range 1–4). Patients who received autologous blood donation had a significantly shorter post-surgical length of stay than patients who did not (p = .002, Mann-Whitney test). Patients who did not donate and preemptively receive autologous blood received significantly more allogenous blood (Mann-Whitney, p=.0004). Moreover 15% of those who auto-donated were given allogenic transfusions, while 37% of those who did not auto-donate were given allogeneic transfusions. One patient who did receive autologous transfusion and was discharged on day 2 sustained an NSAID induced GI-bleed 3 weeks postop and was admitted for transfusion and treatment. There were no other readmissions in either group. Conclusions. Patients who receive pre-emptive autologous blood transfusion intra-operatively when treated specifically by total hip arthroplasty using the superior capsulotomy technique under general anesthesia have shorter hospital stays and lower allogenous transfusion rates than a matched cohort of patients that did not donate and receive autogenous blood

Introduction. The current study reports on the impact of immediate mobilization of patients treated by tissue-preserving, computer-assisted total hip arthroplasty on length of stay, disposition, and complications. Methods. From March, 2010 to April, 2011, a total of 231 consecutive primary THA were performed. Of these, 218 hips met the inclusion criteria of treatment using the superior capsulotomy surgical technique. 1. (Fig. 1), navigation of acetabular component implantation using a patient-specific mechanical navigation device (HipSextant™ navigation System, Surgical Planning Associates, Inc., Boston, MA). 2. , and patient age less than 80 years. Mean age of the patients was 57.3 years (range 23.5–79.9 years). The superior capsulotomy approach. 1. was used in all cases. This technique allows for both the femoral and the acetabular components to be placed with the patient in a lateral position through an incision in the superior capsule, posterior to the abductors and anterior to the short external rotators. The hip is not dislocated during surgery. Rather, the femur is prepared in situ through the top of the femoral neck, the neck is then transected, and the femoral head is excised en bloc. The acetabulum is prepared under direct vision using angled reamers, and the socket is placed with an offset inserter. The final construct is then reduced in situ. The protocol also involved the use of pre-emptive oral analgesia, pre-emptive autologous blood transfusion, and immediate mobilization. 3. Length of stay and disposition in this study group were compared to a cohort of 698 total hip arthroplasty performed at the same institution by all other techniques. Results. In the 218 hips in this study, the mean length of stay was 1.65 days with 97% of patients discharged directly home. Comparatively, the control group of 698 primary hips had an average length of stay of 3.2 days with 68% of patients discharged directly home. Of the 3 patients transferred to rehabilitation, one had cerebral palsy and another had end stage renal disease, a mechanical heart valve, and a longstanding complete sciatic palsy on the contralateral side. One patient, discharged on post op day 3, was readmitted 3 weeks postop for a GI bleed in association with prolonged anti-inflammatory use prior to surgery. Otherwise, there were no readmissions, reoperations, dislocations, nerve injuries, or post-discharge blood transfusions. Conclusions. The current study demonstrates that performing THA with combined tissue preservation and mechanical navigation techniques together with immediate mobilization can be safe and effective and have the potential of greatly reducing healthcare costs and dependence upon prolonged institutionalization following surgery

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end-stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Introduction. Precise knowledge of the Femoral Head (FH) arterial supply is critical to avoid FH avascular necrosis following open and arthroscopic intra-capsular surgical procedures about the hip. The Medial Femoral Circumflex Artery (MFCA) provides the primary FH vascular contribution. Distribution of vascular foramina at the Femoral Head-Neck Junction (FHNJ) has been reported previously using an imaginary clock face. However, no quantitative information exists on the precise Capsular Insertion (CI) and intra-capsular course of the MFCA Terminal Branches (TBs) supplying the FH. This study seeks to determine the precise anatomic location of the MFCA's TBs supplying the FH, in order to help avoid iatrogenic vascular damage during surgical intervention. Methods. In 14 fresh-frozen cadaveric hips (9 left and 5 right), we cannulated the MFCA and injected a polyurethane compound. Using a posterior approach, careful dissection of the MFCA allowed us to identify and document the extra- and intra-capsular course of the TBs penetrating the FHNJ and supplying the FH. An H-type capsulotomy provided joint access while preserving the intracapsular Retinaculum of Weitbrecht (RW), followed by circumferential capsulotomy at the acetabular margin exposing the FH. The dome of the FH was osteotomized 5 mm proximal to the Articular Border (AB) providing a flat surface for our 360° scale. Right-side equivalents were used for data processing. Results. Gross dissection revealed a constant single branch arising from the transverse MFCA penetrating the capsule at the level of the anterior-inferior neck at 177° (range 167–187°), then courses within the medial RW obliquely (elevated from the neck) to the posterior-inferior FHNJ (Figure 1). This vessel was found to have an average of 5 TBs (range 3–9) penetrating the inferior FHNJ 4 mm (range 1–7 mm) from the AB at 204° (range 145–244°; 14% . 10. /. 69. anterior; 86% . 59. /. 69. posterior). In 79% (. 11. /. 14. ) of specimens, an average of 1.5 branches (range 1–3) arising from the ascending MFCA entered the Femoral Capsular Attachment (FCA) at 244° (range 216–269°), running subsynovial through the neck, and terminating in 2 TBs (range 1–3) penetrating the inferior-posterior FHNJ 5 mm (range 3–9) from the AB at 254° (range 207–281°). The deep branch of the MFCA penetrated the FCA at 327° (range 310–335°) providing an average of 6 TBs (range 4–9) running subsynovial and within the lateral RW, finally penetrating the superior FHNJ 6 mm (range 4–9) from the AB at 339° (range 286–25°; 20%. 15/74. anterior; 80%. 59/74. posterior). Discussion and Conclusion. This study demonstrates that TBs of the MFCA penetrate the joint through the mid-substance of the capsule (from the transverse MFCA) or the FCA (from the ascending or deep MFCA). Once intra-capsular, these vessels course subsynovial or within the RW and terminate at the posterior FHNJ superiorly (from the deep MFCA) and inferiorly (from the ascending and transverse MFCA). Any surgical hip intervention should preserve the posterior FCA, and lateral and medial RW in order to preserve the FH vascular supply. These results illustrate a vascular danger zone that should be respected during surgery and can be easily interpreted with the commonly used clock face

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels Type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilisation with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries