Aims

Lateral femoral cutaneous nerve (LFCN) injury is a complication after periacetabular osteo-tomy (PAO) using an anterior approach, which might adversely affect the outcome. However, no prospective study has assessed the incidence and severity of this injury and its effect on the clinical outcomes over a period of time for longer than one year after PAO. The aim of this study was to assess the incidence and severity of the symptoms of LFCN injury for ≥ three years after PAO and report its effect on clinical outcomes.

Several radiological methods of measuring anteversion of the acetabular component after total hip replacement (THR) have been described. These studies used different definitions and reference planes to compare methods, allowing for misinterpretation of the results. We compared the reliability and accuracy of five current methods using plain radiographs (those of Lewinnek, Widmer, Liaw, Pradhan, and Woo and Morrey) with CT measurements, using the same definition and reference plane. We retrospectively studied the plain radiographs and CT scans in 84 hips of 84 patients who underwent primary THR. Intra- and inter-observer reliability were high for the measurement of inclination and anteversion with all methods on plain radiographs and CT scans. The measurements of inclination on plain radiographs were similar to the measurements using CT (p = 0.043). The mean difference between CT measurements was 0.6° (-5.9° to 6.8°).

Measurements using Widmer’s method were the most similar to those using CT (p = 0.088), with a mean difference between CT measurements of -0.9° (-10.4° to 9.1°), whereas the other four methods differed significantly from those using CT (p < 0.001).

This study has shown that Widmer’s method is the best for evaluating the anteversion of the acetabular component on plain radiographs.

Cite this article: Bone Joint J 2014; 96-B:597–603.

The two-incision technique uses strategically located incisions to insert the prosthesis components in to specific intermuscular or internervous planes in an effort to minimize damage to these tissues. Even though there are many reports about safety and benefits of bilateral simultaneous total hip arthroplasty (THA), none of them has reported about either one-incision or two-incision bilateral simultaneous minimally invasive (MI) THA. This study aimed to assess the feasibility of bilateral simultaneous MI two-incision THA in terms of clinical, radiological and functional outcomes.

Sixty two patients, in the age of 24 to 69 years were operated for bilateral simultaneous THA using modified two-incision technique and followed for average 41 months. In the technique of two-incision THA described by Mears, they used modification of Smith Peterson approach for insertion of acetabular component and femoral component is inserted through a small incision situated between greater trochanter and iliac crest, centered directly in line with the femoral shaft. We modified this technique and used part of Watson Jones approach for insertion of acetabular component with patient in lateral position. The posterior incision for insertion of femoral component is through intermuscular interval between gluteus medius and piriformis.

The average Harris Hip score improved from 41.8 (range 10 to 59) preoperatively to 95.3 (range 73 to 100) postoperatively (P < 0.05). WOMAC score improved from median of 66.2 (range 31 to 96) preoperatively to 5.0 (range 0 to 19) postoperatively (P < 0.05). Forty-nine (79.03%) patients were pain-free at the time of first follow up (6 weeks after surgery) and remained pain-free till the last follow up, while remaining 13 (20.97%) had only slight pain. Out of those 13, 3 patients complained of occasional mild pain at last follow up. Fifty (80.64%) patients were walking without limp, while remaining 12 (19.35%) had only slight limp at 6 months. Out of those 12, 2 patients had persistent limp at final follow up. Fifty-eight (93.53%) patients were walking without support, 56 (90.32%) were able to walk unlimited distance and 55 (88.70%) were able to climb stairs without using a railing. Walking with walker was started on average 3.7 days (range 1 to14 days) and walking with crutches was started on average 10.3 days (range 1 to 49 days) postoperatively. Patients were able to walk without support on an average 48 days (range 14 to 120 days) and use stairs without support and without any discomfort on an average of 50 days (range 5 to 150 days). The average lateral opening angle of acetabulum was 40 ° and anteversion was 12 °. All femoral components were implanted in neutral to 5 ° valgus position. None of the femoral component showed subsidence of more than 3 mm. The filling of the femoral canal by the prosthesis was excellent in all cases. Post-operative periprosthetic fracture occurred in 2 patients and delayed infection occurred in 1 patient.

In conclusion, bilateral simultaneous two-incision minimally invasive THA gives satisfactory clinical and radiological results in comparison with conventional THA. It is safe in experienced hands, without any additional risk of complications. It provides excellent functional outcome and patient satisfaction.

This study was undertaken to assess the feasibility of a new subtrochanteric osteotomy technique for total hip arthroplasty (THA) in cases with a high dislocated hip secondary to the sequelae of a septic hip in childhood. Eighteen patients (20 hips), aged 25 to 65 years (average 47.3 years), underwent THA using a cement-less conical stem (Cone prosthesis^®; Protek AG, Berne, Switzerland) with a new subtrochanteric osteotomy technique and were followed for an average of 23.6 months. All patients were graded as type III (high dislocation) according to the Hartofilakidis classification, and according to the Crowe classification 3 cases were of type III and 17 were of type IV.

The procedure was performed through a posterolateral approach and a provisional osteotomy was usually performed at the inferior half of the lesser trochanter. All acetabular component was inserted at the true acetabular and the acetabular cup was inserted in 5 cases and only a liner was inserted after cementing in 15 cases. The stem size and the amount of stem insertion was decided according to the preoperative planning and soft tissue tension. After final reduction, the greater trochanter was re-attached to the proximal femur with the hip in the abducted position. Cables or a grip system (Dall Miles^®, Stryker Orthopaedics Inc., Mahwah, NJ, USA) were used for fixation, and if possible, additional screws were inserted.

Postoperatively, range of motion exercises were encouraged after 2 to 3 weeks of bed rest and non-weight bearing crutch ambulation followed. Weight bearing was permitted only after obtaining radiological confirmation of bone union, but then active exercises were strongly encouraged to stretch abductors. Mean duration of surgery was 180.6 minutes, and mean perioperative blood loss was 1424.1ml. There were no intra-operative complications. Post-operative dislocation occurred in 2 cases and partial femoral nerve palsy developed in 1 case. Mean Harris Hip Score improved from 42.4 to 84.2. Mean lateral opening angle of acetabular cup and liner was 34.7 0 and mean anteversion was 20.8 0. All femoral components were implanted in neutral to 5 degrees of valgus, and mean leg lengthening was 36.5mm. The mean time to greater trochanter union was 3.72 months.

Primary THA in highly dislocated hips due to the sequelae of septic hip in childhood using the described subtrochanteric osteotomy and a cone prosthesis was found to be safe and effective at restoring leg length and trochanteric rotation. But more follow-up is required to more comprehensively establish the long-term results of the described procedure.

Introduction: Osteonecrosis of the femoral head remains a challenging problem especially in young patients. The purpose of this study was to evaluate the clinical results of a viable iliac bone graft for treating osteonecrosis of the femoral head.

Materials and Methods: Seventy-one hips in 52 patients underwent a viable iliac bone graft (9 hips-vessel pedicle iliac bone graft and 62 hips-muscle pedicle iliac bone graft). The clinical and radiographic results were evaluated after an average of 3 years and 4 months (range, 2 to 5 years). Patient age ranged from 20 to 40 years with an average of 31 years. Twenty-three hips were classified as Ficat stage 2 disease and 48 as stage 3 disease. The causes of osteonecrosis were excessive alcohol consumption in 30, steroid use in 13, posttraumatic in 4, decompression sickness in 1, and unknown in 23 hips. The clinical results were evaluated based on the patients’ satisfaction and pain score. The radiographical results were evaluated by serial follow-up roentgenography and pinhole bone scintigraphy.

Results: The clinical and radiological results were satisfactory. Overall, the survival rate was 96 percent. Excellent results were obtained in 15 hips, good in 39, fair in 6 and poor in 8. Three hips underwent total hip replacement, including one infected case. Excellent or good results were obtained in 82 percent of stage 2 cases and in 65 percent of stage 3 cases. The serial roentgenographic examination revealed a gradual incorporation of the grafted bone, and the scintigraphic examination revealed a gradual increase in the uptake which suggested an increased blood supply to the femoral head.

Discussion: The overall results of viable iliac crest bone grafting were very satisfactory. This technique is recommended particularly for young patients with stage 2 or 3 osteonecrosis of the femoral head. Pinhole bone scintigraphy was quite useful for evaluating the healing process after the revascularization procedure.