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

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

Aims. The hip’s capsular ligaments passively restrain extreme range of movement (ROM) by wrapping around the native femoral head/neck. We determined the effect of hip resurfacing arthroplasty (HRA), dual-mobility total hip arthroplasty (DM-THA), conventional THA, and surgical approach on ligament function. Materials and Methods. Eight paired cadaveric hip joints were skeletonized but retained the hip capsule. Capsular ROM restraint during controlled internal rotation (IR) and external rotation (ER) was measured before and after HRA, DM-THA, and conventional THA, with a posterior (right hips) and anterior capsulotomy (left hips). Results. Hip resurfacing provided a near-native ROM with between 5° to 17° increase in IR/ER ROM compared with the native hip for the different positions tested, which was a 9% to 33% increase. DM-THA generated a 9° to 61° (18% to 121%) increase in ROM. Conventional THA generated a 52° to 100° (94% to 199%) increase in ROM. Thus, for conventional THA, the capsule function that exerts a limit on ROM is lost. It is restored to some extent by DM-THA, and almost fully restored by hip resurfacing. In positions of low flexion/extension, the posterior capsulotomy provided more normal function than the anterior, possibly because the capsule was shortened during posterior repair. However, in deep flexion positions, the anterior capsulotomy functioned better. Conclusion. Native head-size and capsular repair preserves capsular function after arthroplasty. The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments. Cite this article: Bone Joint J 2019;101-B:426–434

We used Laser Doppler flowmetry to measure the effect on the blood flow to the femoral head/neck junction of two surgical approaches during resurfacing arthroplasty. We studied 24 hips undergoing resurfacing arthroplasty for osteoarthritis. Of these, 12 had a posterior approach and 12 a trochanteric flip approach. A Laser probe was placed under radiological control in the superolateral part of the femoral head/neck junction. The Doppler flux was measured at stages of the operation and compared with the initial flux. In both groups the main fall in blood flow occurred during the initial exposure and capsulotomy of the hip joint. There was a greater reduction in blood flow with the posterior (40%) than with the trochanteric flip approach (11%)

The hip joint capsular ligaments (CL) passively restrain extreme range of motion (ROM) by wrapping around the native femoral head, and protect against impingement, edge loading wear and dislocation. This study compared how ligament function was affected by device (hip resurfacing arthroplasty, HRA; dual mobility total hip arthroplasty, DM-THA; and conventional THA, C-THA), with and without CL repair. It was hypothesized that ligament function would only be preserved when native anatomy was preserved: with restoration of head-size (HRA or DM-THA) and repair. Eight normal male cadaveric hips were skeletonised, retaining the hip capsule. CL function was quantified 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 and HRA, and C-THA and DM-THA, before and after surgical CL repair. ROM increased most following C-THA (max 62°), then DM-THA (max 40°), then HRA (max 19°), indicating later engagement of the capsule 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. When HRA was combined with 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 resulting in near-native function in some positions, but increased ROM when ligaments were unable to wrap around the head/neck. Following 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 (resurfacing or dual-mobility) and repairing the capsular ligaments may protect against instability in the early postoperative period

The current study aimed to determine the influence of acetabular coverage and intraarticular pathology on post-operative functional outcomes of arthroscopy for cam type FAI. Based on 762 hip scopes performed by a single surgeon between 2013 and 2016, we excluded patients with previous surgery on the hip, mixed FAI, surgical hip dislocation, and missing outcome scores. From this, 97 hips between the ages 17 and 48 that underwent arthroscopy for cam deformity were identified for analysis. Every patient received a partial capsulotomy, cam resection and either labral repair or resection. Measurements for acetabular coverage consisted of pre-operative lateral edge angle (LCEA) (mean 30°, range: 15.4°–40°) and three-dimensional anterior and posterior acetabular coverages. Intraoperative Beck scores were acquired from operative reports, and Hip Disability and Osteoarthritis Outcome Score (HOOS) was collected pre- and post-operatively. Significant post-operative improvement was found in scores of all categories of the HOOS (p < 0.05). However, improvement in HOOS was not correlated with the LCEA, anterior coverage, or posterior coverage. There was a trend toward lower Beck grades (1–3) resulting in better HOOS outcomes than higher Beck grades (4–5). Also, lower Beck grades showed significantly lower alpha angle (mean = 55.86) than higher grades (mean = 73.48). We showed that cam FAI arthroscopic resection improved patient outcome, and confirmed the relationship between the Beck score and functional outcome. However, functional improvement was not related to acetabular coverage suggesting that the so-called “borderline” dysplasia is not a useful radiographic indicator for surgical management

Aims

It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively.

Aims

Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on.

Aims

The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome.

Aims

The purpose of this study was to compare the clinical, radiological, and patient-reported outcome measures (PROMs) in the first 100 consecutive patients undergoing total hip arthroplasty (THA) via a direct superior approach (DSA) with a matched group of patients undergoing THA by the same surgeon, using a posterolateral approach (PLA).

The primary source for the blood supply of the head of the femur is the deep branch of the medial femoral circumflex artery (MFCA). In posterior approaches to the hip and pelvis the short external rotators are often divided. This can damage the deep branch and interfere with perfusion of the head. We describe the anatomy of the MFCA and its branches based on dissections of 24 cadaver hips after injection of neoprene-latex into the femoral or internal iliac arteries. The course of the deep branch of the MFCA was constant in its extracapsular segment. In all cases there was a trochanteric branch at the proximal border of quadratus femoris spreading on to the lateral aspect of the greater trochanter. This branch marks the level of the tendon of obturator externus, which is crossed posteriorly by the deep branch of the MFCA. As the deep branch travels superiorly, it crosses anterior to the conjoint tendon of gemellus inferior, obturator internus and gemellus superior. It then perforates the joint capsule at the level of gemellus superior. In its intracapsular segment it runs along the posterosuperior aspect of the neck of the femur dividing into two to four subsynovial retinacular vessels. We demonstrated that obturator externus protected the deep branch of the MFCA from being disrupted or stretched during dislocation of the hip in any direction after serial release of all other soft-tissue attachments of the proximal femur, including a complete circumferential capsulotomy. Precise knowledge of the extracapsular anatomy of the MFCA and its surrounding structures will help to avoid iatrogenic avascular necrosis of the head of the femur in reconstructive surgery of the hip and fixation of acetabular fractures through the posterior approach

Aims

There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients.

Aims

Optimal exposure through the direct anterior approach (DAA) for total hip arthroplasty (THA) conducted on a regular operating theatre table is achieved with a standardized capsular releasing sequence in which the anterior capsule can be preserved or resected. We hypothesized that clinical outcomes and implant positioning would not be different in case a capsular sparing (CS) technique would be compared to capsular resection (CR).

Aims

The direct anterior approach (DAA) for total hip arthroplasty (THA) has potential advantages over other approaches and is most commonly performed with the patient in the supine position. We describe a technique for DAA THA with the patient in the lateral decubitus position and report the early clinical and radiological outcomes, the characteristics of the learning curve, and perioperative complications.

Aims

Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature.

Aims

Whether patient-reported pain differs among surgical approaches in total hip arthroplasty (THA) remains unclear. This study’s purposes were to determine differences in pain based on surgical approach (direct anterior (DA) vs posterolateral (PL)) and PL approach incision length.

Aims

Several studies have reported the safety and efficacy of subcapital re-alignment for patients with slipped capital femoral epiphysis (SCFE) using surgical dislocation of the hip and an extended retinacular flap. Instability of the hip and dislocation as a consequence of this surgery has only recently gained attention. We discuss this problem with some illustrative cases.

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.

This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip.

Cite this article: Bone Joint J 2013;95-B:10–19.

Aims

We aimed to quantify the relative contributions of the medial femoral circumflex artery (MFCA) and lateral femoral circumflex artery (LFCA) to the arterial supply of the head and neck of the femur.

Aims

We wished to quantify the extent of soft-tissue damage sustained during minimally invasive total hip arthroplasty through the direct anterior (DA) and direct superior (DS) approaches.