Aims. This study aimed to explore whether intraoperative nerve monitoring can identify risk factors and reduce the incidence of nerve injury in patients with high-riding developmental dysplasia. Patients and Methods. We conducted a historical controlled study of patients with unilateral Crowe IV developmental dysplasia of the hip (DDH). Between October 2016 and October 2017, intraoperative nerve monitoring of the femoral and sciatic nerves was applied in total hip arthroplasty (THA). A neuromonitoring technician was employed to monitor nerve function and inform the surgeon of ongoing changes in a timely manner. Patients who did not have intraoperative nerve monitoring between September 2015 and October 2016 were selected as the control group. All the surgeries were performed by one surgeon. Demographics and clinical data were analyzed. A total of 35 patients in the monitoring group (ten male, 25 female; mean age 37.1 years (20 to 46)) and 56 patients in the control group (13 male, 43 female; mean age 37.9 years (23 to 52)) were enrolled. The mean follow-up of all patients was 13.1 months (10 to 15). Results. The two groups had no significant differences in preoperative data. In the monitoring group, ten nerve alerts occurred intraoperatively, and no neural complications were detected postoperatively. In the control group, six patients had neural complications. The rate of nerve injury was lower in the monitoring group than in the control group, but this did not achieve statistical significance. The degree of leg lengthening was significantly greater in the monitoring group than in the control group. In further analyses, patients who had previous hip surgery were more likely to have intraoperative nerve alerts and postoperative nerve injury. Conclusion. Nerve injury usually occurred during the processes of exposure and reduction. The use of intraoperative nerve monitoring showed a trend towards reduced nerve injury in THA for Crowe IV DDH patients. Hence, we recommend its routine use in patients undergoing leg lengthening, especially in those with previous hip surgery. Cite this article: Bone Joint J 2019;101-B:1438–1446

The purpose of this study was to establish whether exploration and neurolysis is an effective method of treating neuropathic pain in patients with a sciatic nerve palsy after total hip replacement (THR). A total of 56 patients who had undergone this surgery at our hospital between September 1999 and September 2010 were retrospectively identified. There were 42 women and 14 men with a mean age at exploration of 61.2 years (28 to 80). The sciatic nerve palsy had been sustained by 46 of the patients during a primary THR, five during a revision THR and five patients during hip resurfacing. The mean pre-operative visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were significantly different (p < 0.001). Based on the findings of our study, we recommend this form of surgery over conservative management in patients with neuropathic pain associated with a sciatic nerve palsy after THR. Cite this article: Bone Joint J 2013;95-B:20–2

1. The results of repair of the sciatic nerve and of its main divisions have been analysed in a series of 118 cases, the patients having been under observation for three to eighteen years (average 11·7 years). 2. A result was satisfactory if there was some return of sensibility throughout the autonomous zone (the area of skin supplied exclusively by the damaged nerve) and if the more important muscles of the leg were capable of contraction against gravity and resistance. 3. When the whole of the sciatic nerve is damaged it is necessary to present the results separately for the lateral and medial popliteal divisions. 4. Of forty-seven cases of repair of the medial popliteal nerve 79 per cent showed useful motor and 62 per cent useful sensory recovery. In three out of four cases the correspondence between the degree of motor and of sensory recovery was fairly close. 5. Of seventy-two cases of repair of the lateral popliteal nerve 36 per cent showed useful motor and 74 per cent useful sensory recovery. The latter figure must be regarded with some reserve because sensory "recovery" in the lateral popliteal zone may be due to the ingrowth of nerve fibres from contiguous normally innervated skin. Thus it is not possible to correlate motor and sensory recovery. 6. In eighteen cases of repair of the posterior tibial nerve, there was useful sensory recovery in the sole in twelve. But although there was evidence of recovery in the plantar muscles in eleven cases it was functionally valueless. 7. In repair of the medial popliteal nerve the result was better if suture had been carried out early. In repair of the lateral popliteal nerve there was no evidence that delay was harmful; but the proportion of good results was so low (as judged by motor function alone, sensory recovery being often extraneous) that this exception to a general rule cannot be taken very seriously. 8. Gaps of up to twelve centimetres–estimated after resection of the damaged nerve ends–could be closed without difficulty by the usual technique, and the extent of the gap up to that limit had no influence on the prognosis. The closure of larger gaps, when the knee must be flexed beyond a right angle, is not compatible with good recovery because the post-operative stretching of the nerve causes serious intraneural damage. 9. Nerve grafting has given poor results in repair of the sciatic nerve

We report a case of iatrogenic sciatic nerve injury caused by pre-operative intraneural injection of local anaesthetic at total hip replacement. To our knowledge, this is unreported in the orthopaedic literature. We consider sacral nerve blockade in patients undergoing total hip replacement to be undesirable and present guidelines for the management of peri-operative sciatic nerve injury

1. We have described what happens to patients a number of years after injury of the sciatic nerve or of its divisions; there were 329 who had been under observation for periods ranging from three to eighteen years. The neurological recovery was recorded in every case and, more important, the behaviour of the limb as appreciated by the patient. 2. Although it was generally true that good neurological recovery and good function went together there were remarkable discrepancies. Isolated paralysis of the medial popliteal or of the lateral popliteal nerve was often compatible with good function, though patients with lateral popliteal paralysis usually needed toe-raising apparatus. Even total sciatic paralysis sometimes gave little trouble. 3. Of the various types of injury, clean wounds and traction lesions led to rather better than average return of function. 4. Some degree of pain was present in about half the cases, and over-response–exaggerated and painful response to an ordinary stimulus–was present in one-third of the cases. 5. Repair of the posterior tibial nerve was rarely worth while; no less than eight out of twelve patients with this type of injury exhibited over-response. 6. One-third of the patients showed vasomotor and trophic disorders: coldness of the affected limb, erythema, thinness or pigmentation of the skin, changes in the nails or oedema. 7. Pressure sores were the most serious consequence of sciatic nerve injury and at some time or other were present in 14 per cent of our patients. The cause was deformity rather than insensibility of the sole. 8. Of the various palliative operations Lambrinudi's tarsal arthrodesis gave such disappointing results that we doubt whether the operation is worth doing. Tenodesis, revived as a time-saving expedient during the war, was a failure. For lateral popliteal paralysis anterior transplantation of tibialis posterior is excellent. 9. Amputation was done in only ten cases. When it was performed for fixed deformity with secondary ulceration the result was satisfactory. When it was done because of pain there was no relief. Amputation is, therefore, avoidable provided that vigorous steps are taken to prevent or correct deformity; it should not be done for the relief of pain

Injuries to the sciatic nerve are an occasional complication of surgery to the hip and acetabulum, and traction is frequently the causative mechanism. In vitro and animal experiments have shown that increased tensile strain on peripheral nerves, when applied for prolonged periods, impairs nerve function. We have used video-extensometry to measure strain on the human sciatic nerve during total hip replacement (THR). Ten consecutive patients with a mean age of 72 years undergoing primary THR by the posterior approach were recruited, and strains in the sciatic nerve were measured in different combinations of flexion and extension of the hip and knee, before dislocation of the hip. Significant increases (p = 0.02) in strain in the sciatic nerve were observed in flexion of the hip and extension of the knee. The mean increase was 26% (19% to 30%). In animal studies increases of this magnitude have been shown to impair electrophysiological function in peripheral nerves. Our results suggest that excessive flexion of the hip and extension of the knee should be avoided during THR

Injury to the sciatic nerve following closed manipulation of a dislocated total hip replacement is rare. We present such a case in an elderly patient with partial recovery following exploration and release of the nerve

Traction injury to the sciatic nerve can occur during hamstring lengthening. The aim of this study was to monitor the influence of hamstring lengthening on conduction in the sciatic nerve using evoked electromyography (EMG). Ten children with spastic cerebral palsy underwent bilateral distal hamstring lengthening. Before lengthening, the evoked potential was recorded with the patient prone. During lengthening, it was recorded with the knee flexed to 90°, 60° and 30°, and at the end of lengthening with the hip and knee extended. In all patients, the amplitude of the evoked EMG gradually decreased with increasing lengthening. The mean decrease with the knee flexed to 60° was 34% (10 to 77), and to 30°, 86% (52 to 98) compared with the pre-lengthening amplitude. On hip extension at the end of the lengthening procedure, the EMG returned to the pre-lengthening level. Monitoring of the evoked EMG potential of the sciatic nerve during and after hamstring lengthening, may be helpful in preventing traction injury

We present simple but effective retractors used in pairs to expose the sciatic notch during Salter innominate osteotomy. We have found them to be useful for a wide range of procedures requiring similar exposure. We present them here in tribute to the memory of the designer Mercer Rang

We describe a patient with a painful sciatic neuropathy after total hip arthroplasty. Treatment was confined to neuroleptic and analgesic agents until neurolysis at seven years abolished pain and restored function

We describe a 47-year-old woman with sciatic neuropathy caused by compression of the sacral plexus by posterior shift of the uterus

We present the case of a 63-year-old woman who sustained an acrylic cement burn of the sciatic nerve at hip replacement. She was treated by resection of the damaged segment and grafting. Electron microscopy showed that the nerve was nearly normal 1 cm from the cement margin indicating that this is a safe level for resection

Pain in the distribution of the sciatic nerve is common in the elderly. In the presence of a long-standing joint replacement, consideration should be given as to whether compression might be due to an extraspinal cause. We present three women, in whom a mass of wear debris from a previous total hip replacement caused compression of the sciatic nerve posterior to the hip. The symptoms were relieved immediately following operation

Experiments have shown that the tension of the sciatic nerve roots is increased when the posterior tibial nerve is pressed upon in the popliteal space. A refinement of the straight leg raising test, based on this observation, is described

We describe a patient in whom an initially intact sciatic nerve became rapidly encased in heterotopic bone formed in the abductor compartment after reconstruction of the posterior wall of the acetabulum following fracture. Prompt excision and neural release followed by irradiation and administration of indometacin resulted in a full neurological recovery and no recurrence 27 months later

Severe leg pain in a patient after total hip replacement was found to be caused by compression of the sciatic nerve by methylmethacrylate cement which had leaked from the acetabulum during fixation of the acetabular cup. The pain persisted for six years but was immediately relieved by removal of the cement mass

The right sciatic nerve of 50 one-month-old male rats was cut under general anaesthesia. Groups of animals were sacrificed at intervals of up to 12 weeks after operation and the length of the femora, tibiae and first and fifth metatarsals were measured with a caliper accurate to 0.05 mm. From the first week, both metatarsals were between 3% and 5% shorter on the denervated side, but there was no further increase of the discrepancy. The femora were less than 1% longer in the denervated limb at the second and eighth week. No difference was found between the lengths of the tibiae. The various factors which could possibly be responsible for these findings are discussed

1. Between 1936 and 1945, 525 patients with sciatic pain were treated at the Princess Elizabeth Orthopaedic Hospital, Exeter. Of these, 225 had neurological signs and they were selected for review; 147 were traced. 2. Of these, 123 were treated by means of plaster jackets and twenty-four were treated by other methods. The late results of treatment in the two groups were about the same, roughly one-third being "cured," one-third "relieved," and one-third "not relieved.". 3. Nevertheless examination of the immediate results suggests that protection by means of a plaster jacket had at least a palliative effect, relieving acute symptoms and allowing early rehabilitation. Moreover it should be emphasised that in limiting the investigation to cases of sciatica with evidence of nerve root pressure only the more severe cases have been included. 4. Permanent relief after immobilisation in plaster was greatest when the duration of symptoms was short, and when the patient was treated during his first attack. It was least in patients who showed all three signs of nerve root pressure—diminished ankle jerks, hypo-aesthesia, and muscle hypotonicity. 5. Absence of tendon reflexes due to nerve root pressure, and areas of hypo-aesthesia, tend to remain permanently; but diminution of reflexes and loss of muscle power may recover

An orientated substratum has been implicated in the development and regeneration of axons and synapses. We prepared a basement membrane matrix from autogenous striated muscle, used it to repair the sciatic nerve in rats, then investigated the results by histology and electrophysiology. When treated grafts were coaxially aligned with the nerve fascicles functional recovery appeared within 30 days, with good growth of axons into the distal nerve. Grafts with myotubes at right angles to the nerve fascicles supported nerve regeneration but at a slower rate. Grafts of coaxially aligned but untreated muscle allowed axon penetration only through naturally degenerated muscle fibres, with minimal axon penetration of the distal nerve. It is concluded that in the rat a treated graft with correctly orientated empty myotubes can facilitate and guide the regeneration of peripheral nerve after injury and so lead to recolonisation of the distal stump with functional recovery

1. The risk of injury to the sciatic nerve during closed ischio-femoral arthrodesis by nail and graft has been assessed on the basis of clinical evidence and of anatomical studies in the living and in cadavers. 2. The margin of safety for the nerve is nearly always small. 3. The risk of injury to the nerve is prohibitive when there is marked deformity or hypoplasia of the pelvis. The risk is also increased when the buttock is compressed against the table and, because of the technical difficulties that are entailed, when the hip is in marked flexion. The risk is probably greater in children than in adults. 4. In properly selected cases in which none of these adverse factors is present it is submitted that the risk of nerve injury can be eliminated by proper attention to surgical technique and by the observance of certain definite precautions. 5. When there is doubt in the surgeon's mind about his ability to complete the operation without injuring the nerve the closed technique should be abandoned in favour of the open posterior approach

1. A case of complete sciatic palsy complicating anticoagulant therapy is presented.

2. A brief review of the possible pathogenesis is made and the importance of early recognition and treatment of the syndrome is emphasised.

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis. After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy. Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve. Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment. Cite this article: Bone Joint J 2020;102-B(5):556–567

The aim of this cadaver study was to identify the change in position of the sciatic nerve during arthroplasty using the posterior surgical approach to the hip. We investigated the position of the nerve during this procedure by dissecting 11 formalin-treated cadavers (22 hips: 12 male, ten female). The distance between the sciatic nerve and the femoral neck was measured before and after dislocation of the hip, and in positions used during the preparation of the femur. The nerve moves closer to the femoral neck when the hip is flexed to > 30° and internally rotated to 90° (90° IR). The mean distance between the nerve and femoral neck was 43.1 mm (standard deviation (. sd. ) 8.7) with the hip at 0° of flexion and 90° IR; this significantly decreased to a mean of 36.1 mm (. sd. 9.5), 28.8 mm (. sd. 9.8) and 19.1 mm (. sd. 9.7) at 30°, 60° and 90° of hip flexion respectively (p < 0.001). In two hips the nerve was in contact with the femoral neck when the hip was flexed to 90°. . This study demonstrates that the sciatic nerve becomes closer to the operative field during hip arthroplasty using the posterior approach with progressive flexion of the hip. Cite this article: Bone Joint J 2015;97-B:1056–62

Sciatic nerve palsy is a recognised complication of primary total hip replacement. In our unit this complication was rare with an incidence of < 0.2% in the past ten years. We describe six cases of sciatic nerve palsy occurring in 355 consecutive primary total hip replacements (incidence 1.69%). Each of these palsies was caused by post-operative haematoma in the region of the sciatic nerve. Cases, which were recognised early and surgically-evacuated promptly, showed earlier and more complete recovery. Those patients for whom the diagnosis was delayed, and who were therefore managed expectantly, showed little or no recovery. Unexpected pain and significant swelling in the buttock, as well as signs of sciatic nerve irritation, suggest the presence of haematoma in the region of the sciatic nerve. It is, therefore, of prime importance to be vigilant for the features of a sciatic nerve palsy in the early post-operative period as, when recognised and treated early, the injury to the sciatic nerve may be reversed

Aims. Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants. Methods. A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed. Results. At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint. Conclusion. The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J 2021;103-B(7 Supple B):129–134

The modified Smith–Petersen and Kocher–Langenbeck approaches were used to expose the lateral cutaneous nerve of the thigh and the femoral, obturator and sciatic nerves in order to study the risk of injury to these structures during the dissection, osteotomy, and acetabular reorientation stages of a Bernese peri-acetabular osteotomy. Injury of the lateral cutaneous nerve of thigh was less likely to occur if an osteotomy of the anterior superior iliac spine had been carried out before exposing the hip. The obturator nerve was likely to be injured during unprotected osteotomy of the pubis if the far cortex was penetrated by > 5 mm. This could be avoided by inclining the osteotome 45° medially and performing the osteotomy at least 2 cm medial to the iliopectineal eminence. . The sciatic nerve could be injured during the first and last stages of the osteotomy if the osteotome perforated the lateral cortex of ischium and the ilio-ischial junction by > 10 mm. The femoral nerve could be stretched or entrapped during osteotomy of the pubis if there was significant rotational or linear displacement of the acetabulum. Anterior or medial displacement of < 2 cm and lateral tilt (retroversion) of < 30° were safe margins. The combination of retroversion and anterior displacement could increase tension on the nerve. Strict observation of anatomical details, proper handling of the osteotomes and careful manipulation of the acetabular fragment reduce the neurological complications of Bernese peri-acetabular osteotomy. Cite this article: Bone Joint J 2015;97-B:636–41

We investigated the detailed anatomy of the gluteus maximus, gluteus medius and gluteus minimus and their neurovascular supply in 22 hips in 11 embalmed adult Caucasian human cadavers. This led to the development of a surgical technique for an extended posterior approach to the hip and pelvis that exposes the supra-acetabular ilium and preserves the glutei during revision hip surgery. Proximal to distal mobilisation of the gluteus medius from the posterior gluteal line permits exposure and mobilisation of the superior gluteal neurovascular bundle between the sciatic notch and the entrance to the gluteus medius, enabling a wider exposure of the supra-acetabular ilium. This technique was subsequently used in nine patients undergoing revision total hip replacement involving the reconstruction of nine Paprosky 3B acetabular defects, five of which had pelvic discontinuity. Intra-operative electromyography showed that the innervation of the gluteal muscles was not affected by surgery. Clinical follow-up demonstrated good hip abduction function in all patients. These results were compared with those of a matched cohort treated through a Kocher–Langenbeck approach. Our modified approach maximises the exposure of the ilium above the sciatic notch while protecting the gluteal muscles and their neurovascular bundle. Cite this article: Bone Joint J 2014;96-B:48–53

We describe a case of sciatic endometriosis in a 25-year-old woman diagnosed by MRI and histology with no evidence of intrapelvic disease. The presentation, diagnosis and management of this rare condition are described. Early diagnosis and treatment are important to prevent irreversible damage to the sciatic nerve

This study was designed to test the hypothesis that the sensory innervation of bone might play an important role in sensing and responding to low-intensity pulsed ultrasound and explain its effect in promoting fracture healing. In 112 rats a standardised mid-shaft tibial fracture was created, supported with an intramedullary needle and divided into four groups of 28. These either had a sciatic neurectomy or a patellar tendon resection as control, and received the ultrasound or not as a sham treatment. Fracture union, callus mineralisation and remodelling were assessed using plain radiography, peripheral quantitative computed tomography and histomorphology. Daily ultrasound treatment significantly increased the rate of union and the volumetric bone mineral density in the fracture callus in the neurally intact rats (p = 0.025), but this stimulating effect was absent in the rats with sciatic neurectomy. Histomorphology demonstrated faster maturation of the callus in the group treated with ultrasound when compared with the control group. The results supported the hypothesis that intact innervation plays an important role in allowing low-intensity pulsed ultrasound to promote fracture healing

Injury to the sciatic nerve is one of the more serious complications of acetabular fracture and traumatic dislocation of the hip, both in the short and long term. We have reviewed prospectively patients, treated in our unit, for acetabular fractures who had concomitant injury to the sciatic nerve, with the aim of predicting the functional outcome after these injuries. Of 136 patients who underwent stabilisation of acetabular fractures, there were 27 (19.9%) with neurological injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot and four had burning pain and altered sensation over the dorsum of the foot. Serial electromyography (EMG) studies were performed and the degree of functional recovery was monitored using the grading system of the Medical Research Council. In nine patients with a foot-drop, there was evidence of a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, the double-crush syndrome. At the final follow-up, clinical examination and EMG studies showed full recovery in five of the ten patients with initial muscle weakness, and complete resolution in all four patients with sensory symptoms (burning pain and hyperaesthesia). There was improvement of functional capacity (motor and sensory) in two patients who presented initially with complete foot-drop. In the remaining 11 with foot-drop at presentation, including all nine with the double-crush lesion, there was no improvement in function at a mean follow-up of 4.3 years

Aims. Severe acetabular bone loss and pelvic discontinuity (PD) present particular challenges in revision total hip arthroplasty. To deal with such complex situations, cup-cage reconstruction has emerged as an option for treating this situation. We aimed to examine our success in using this technique for these anatomical problems. Patients and Methods. We undertook a retrospective, single-centre series of 35 hips in 34 patients (seven male, 27 female) treated with a cup-cage construct using a trabecular metal shell in conjunction with a titanium cage, for severe acetabular bone loss between 2011 and 2015. The mean age at the time of surgery was 70 years (42 to 85) and all patients had an acetabular defect graded as Paprosky Type 2C through to 3B, with 24 hips (69%) having PD. The mean follow-up was 47 months (25 to 84). Results. The cumulative five-year survivorship of the implant with revision for any cause was 89% (95% confidence interval (CI) 72 to 96) with eight hips at risk. No revision was required for aseptic loosening; however, one patient with one hip (3%) required removal of the ischial flange of the cage due to sciatic nerve irritation. Two patients (6%; two hips) suffered from hip dislocation, whereas one patient (one hip) required revision surgery with cement fixation of a dual-mobility acetababular component into a well-fixed cup-cage construct. Two patients (6%; two hips) developed periprosthetic infection. One patient was successfully controlled with a two-stage revision surgery, while the other patient underwent excision arthroplasty due to severe medical comorbidities. For the whole series, the Harris Hip Score significantly improved from a mean of 30 (15 to 51) preoperatively to 71 (40 to 89) at the latest follow-up (p < 0.001). Conclusion. Our findings suggest that cup-cage reconstruction is a viable option for major segmental bone defects involving the posterior column and PD. It allows adequate restoration of the acetabulum centre with generally good stability and satisfactory postoperative function. Instability and infection remain drawbacks in these challenging revision cases. Cite this article: Bone Joint J 2018;100-B:1442–48

We investigated the effect of progesterone on the nerve during lengthening of the limb in rats. The sciatic nerves of rats were elongated by leg lengthening for ten days at 3 mm per day. On alternate days between the day after the operation and nerve dissection, the progesterone-treated group received subcutaneous injections of 1 mg progesterone in sesame oil and the control group received oil only. On the fifth, tenth and 17th day, the sciatic nerves were excised at the midpoint of the femur and the mRNA expression level of myelin protein P0 was analysed by quantitative real time polymerase chain reaction. On day 52 nodal length was examined by electron microscopy, followed by an examination of the compound muscle action potential (C-MAP) amplitude and the motor conduction velocity (MCV) of the tibial nerve on days 17 and 52. The P0 (a major myelin glycoprotein) mRNA expression level in the progesterone-treated group increased by 46.6% and 38.7% on days five and ten, respectively. On day 52, the nodal length in the progesterone-treated group was smaller than that in the control group, and the MCV of the progesterone-treated group had been restored to normal. Progesterone might accelerate the restoration of demyelination caused by nerve elongation by activating myelin synthesis

The medial displacement osteotomy of Chiari has an established place in the management of older children and adults with severe hip dysplasia. The results claimed for the operation are, however, variable. There have also been reports of sciatic nerve lesions. In this study ten cadavers were operated upon. Chiari osteotomy was performed upon five, and five acted as controls. The hemipelvis was removed from each cadaver; each specimen was deep-frozen and sectioned transversely. The distance of the sciatic nerve from the nearest bony point was measured in each section and the results were recorded graphically. A further radiographic and photographic study was performed to determine whether apparent displacement at the osteotomy might be misleading. The conclusion was drawn that the sciatic nerve is angulated at the osteotomy and further endangered by the risk of bone splintering at the sciatic notch. The radiographic study suggested that some poor clinical results may be explained by a radiological artefact, because there is a tendency for the osteotomy to hinge posteriorly at the sciatic notch opening anteriorly like a book. Radiographs may suggest excellent medial displacement whereas in fact the femoral head is very poorly covered

Sciatic nerve palsy following total hip arthroplasty (THA) is a relatively rare yet potentially devastating complication. The purpose of this case series was to report the results of patients with a sciatic nerve palsy who presented between 2000 and 2010, following primary and revision THA and were treated with neurolysis. A retrospective review was made of 12 patients (eight women and four men), with sciatic nerve palsy following THA. The mean age of the patients was 62.7 years (50 to 72; standard deviation 6.9). They underwent interfascicular neurolysis for sciatic nerve palsy, after failing a trial of non-operative treatment for a minimum of six months. Following surgery, a statistically and clinically significant improvement in motor function was seen in all patients. The mean peroneal nerve score function improved from 0.42 (0 to 3) to 3 (1 to 5) (p < 0.001). The mean tibial nerve motor function score improved from 1.75 (1 to 4) to 3.92 (3 to 5) (p = 0.02).The mean improvement in sensory function was a clinically negligible 1 out of 5 in all patients. In total, 11 patients reported improvement in their pain following surgery. . We conclude that neurolysis of the sciatic nerve has a favourable prognosis in patients with a sciatic nerve palsy following THA. Our findings suggest that surgery should not be delayed for > 12 months following injury. Cite this article: Bone Joint J 2015;97-B:1345–9

Total hip replacement (THR) after acetabular fracture presents unique challenges to the orthopaedic surgeon. The majority of patients can be treated with a standard THR, resulting in a very reasonable outcome. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining long-term acetabular component fixation. Indications for an acute THR include young patients with both femoral head and acetabular involvement with severe comminution that cannot be reconstructed, and the elderly, with severe bony comminution. The outcomes of THR for established post-traumatic arthritis include excellent pain relief and functional improvements. The use of modern implants and alternative bearing surfaces should improve outcomes further. Cite this article: Bone Joint J 2013;95-B, Supple A:11–16

A 60-year-old man developed severe neuropathic pain and foot-drop in his left leg following resurfacing arthroplasty of the left hip. The pain was refractory to all analgesics for 16 months. At exploration, a PDS suture was found passing through the sciatic nerve at several points over 6 cm and terminating in a large knot. After release of the suture and neurolysis there was dramatic and rapid improvement of the neuropathic pain and of motor function. This case represents the human equivalent of previously described nerve ligation in an animal model of neuropathic pain. It emphasises that when neuropathic pain is present after an operation, the nerve related to the symptoms must be inspected, and that removal of a suture or irritant may lead to relief of pain, even after many months

Peripheral nerve injury is an uncommon but serious complication of hip surgery that can adversely affect the outcome. Several studies have described the use of electromyography and intra-operative sensory evoked potentials for early warning of nerve injury. We assessed the results of multimodal intra-operative monitoring during complex hip surgery. We retrospectively analysed data collected between 2001 and 2010 from 69 patients who underwent complex hip surgery by a single surgeon using multimodal intra-operative monitoring from a total pool of 7894 patients who underwent hip surgery during this period. In 24 (35%) procedures the surgeon was alerted to a possible lesion to the sciatic and/or femoral nerve. Alerts were observed most frequently during peri-acetabular osteotomy. The surgeon adapted his approach based on interpretation of the neurophysiological changes. From 69 monitored surgical procedures, there was only one true positive case of post-operative nerve injury. There were no false positives or false negatives, and the remaining 68 cases were all true negative. The sensitivity for predicting post-operative nerve injury was 100% and the specificity 100%. We conclude that it is possible and appropriate to use this method during complex hip surgery and it is effective for alerting the surgeon to the possibility of nerve injury

Aims

A local injection may be used as an early option in the treatment of Morton’s neuroma, and can be performed using various medications. The aim of this study was to compare the effects of injections of hyaluronic acid compared with corticosteroid in the treatment of this condition.

Aims

This study reports mid-term outcomes after periacetabular osteotomy (PAO) exclusively in a borderline hip dysplasia (BHD) population to provide a contrast to published outcomes for arthroscopic surgery of the hip in BHD.

Internal hemipelvectomy is a standard treatment for malignant tumours of the pelvis. Reconstruction using a non-vascularised fibular graft is relatively straightforward compared to other techniques. We describe the surgical and functional outcomes for a series of ten patients who underwent an internal hemipelvectomy (type I or I/IV) with reconstruction by a non-vascularised fibular graft between 1996 and 2009. A key prerequisite for this procedure was a preserved sciatic notch, confirmed pre-operatively on MRI. Graft-host union was achieved in all patients with a single fibular graft, and in the lower graft where two grafts had been used. The mean time to union was 7.3 months (3 to 12). The upper graft did not unite in four of six cases where two grafts had been used. Seven patients were eventually able to walk without a stick. The mean post-operative Musculoskeletal Tumour Society score was 75.4% (16.7 to 96.7). There were no cases of deep post-operative infection. The mean pelvic shortening was 0.9 cm (0.2 to 3.4). Recurrent tumour occurred in three cases, and death from tumour-related disease occured in one. Patients who need an internal hemipelvectomy will do well if their pelvic ring is reconstructed with a non-vascularised fibular graft. The complication rate is low, and they attain a good functional outcome

This retrospective study compared post-operative epidural analgesia (E), continuous peripheral nerve blocks (CPNB) and morphine infusion (M) in 68 children undergoing limb reconstruction with circular frames. The data collected included episodes of severe pain, post-operative duration of analgesia, requirement for top-up analgesia, number of osteotomies, side effects and complications. There was a significant difference between the number of episodes of severe pain in patients receiving a morphine infusion and those receiving epidurals or CPNB (M vs E, p < 0.0001; M vs CPNB, p = 0.018). The CPNB group was associated with the lowest incidence of episodes of severe pain and top-up analgesia. Epidural analgesia was associated with significantly more nausea and vomiting than morphine infusion (p = 0.053) and CPNB (p = 0.023). It also had a significantly higher incidence of motor blockade than CPNB (p < 0.01). We found that the most effective method of post-operative analgesia for children undergoing lower limb reconstruction was sciatic nerve catheterisation and continuous infusion

Aims

The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA).

Aims

Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH.

We report the case of a child with cerebral palsy and spastic diplegia treated for bilateral fixed flexion of the knee by bilateral hamstring lengthening. An attempt to straighten the legs from 90 degrees to 20 degrees flexion damaged the sciatic nerve. There are no objective means of estimating how much deformity can be reduced safely. We present a method of calculating the extra strain in the sciatic nerve produced by reducing a flexion deformity. The result, combined with clinical judgement, provides guidelines for safe corrective surgery

Aims

The use of a porous metal shell supported by two augments with the ‘footing’ technique is one solution to manage Paprosky IIIB acetabular defects in revision total hip arthroplasty. The aim of this study was to assess the medium-term implant survival and radiological and clinical outcomes of this technique.

Aims

Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm². However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

We evaluated the nerve roots of the cauda equina by CT myelography in 36 patients aged from 11 to 19 years with lumbar disc herniation. On straight-leg-raising tests, six younger patients had isolated hamstring tightness with no sciatica (group A) and 30 had sciatic pain (group B). CT myelography showed that no patient in group A had associated nerve-root swelling, and that the roots were displaced posteriorly, but not compressed. In 21 of the group-B patients, swelling of the nerve roots was confirmed, with compression between the herniated disc and the superior articular process. Our findings suggest that hamstring tightness in these patients may be caused by a different mechanism from that which causes sciatic pain

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

Aims

Periacetabular osteotomy (PAO) is the preferred treatment for symptomatic acetabular dysplasia in adolescents and young adults. There remains a lack of consensus regarding whether intra-articular procedures such as labral repair or improvement of femoral offset should be performed at the time of PAO or addressed subsequent to PAO if symptoms warrant. The purpose was to determine the rate of subsequent hip arthroscopy (HA) in a contemporary cohort of patients, who underwent PAO in isolation without any intra-articular procedures.

Aims

Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve.

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.

Aims

Pelvic discontinuity is a challenging acetabular defect without a consensus on surgical management. Cup-cage reconstruction is an increasingly used treatment strategy. The present study evaluated implant survival, clinical and radiological outcomes, and complications associated with the cup-cage construct.

In order to treat painful subluxation or dislocation secondary to cerebral palsy, 11 patients (12 hips) underwent combined femoral and Chiari pelvic osteotomies with additional soft-tissue releases at a mean age of 14.1 years (9.1 to 17.8). Relief of pain, improvement in movement of the hip, and in sitting posture, and ease of perineal care were recorded in all, and were maintained at a mean follow-up of 13.1 years (8 to 17.5). The improvement in general mobility was marginal, but those who were able to walk benefited the most. The radiological measurements made before operation were modified afterwards to use the lateral margin of the neoacetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% (61% to 100%) to 13.7% (0% to 33%) (p < 0.0001). The mean changes in centre edge angle and Sharp’s angle were 72° (56° to 87°; p < 0.0001) and 12.3° (9° to 15.6°; p < 0.0001), respectively. Radiological evidence of progressive arthritic change was seen in one hip, in which only a partial reduction had been achieved, and there was early narrowing of the joint space in another. Painless heterotopic ossification was observed in one patient with athetoid quadriplegia. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve

Aims

Internal hemipelvectomy without reconstruction of the pelvis is a viable treatment for pelvic sarcoma; however, the time it takes to return to excellent function is quite variable. Some patients require greater time and rehabilitation than others. To determine if psoas muscle recovery is associated with changes in ambulatory function, we retrospectively evaluated psoas muscle size and limb-length discrepancy (LLD) before and after treatment and their correlation with objective functional outcomes.

Aims

Dislocation of the hip remains a major complication after periacetabular tumour resection and endoprosthetic reconstruction. The position of the acetabular component is an important modifiable factor for surgeons in determining the risk of postoperative dislocation. We investigated the significance of horizontal, vertical, and sagittal displacement of the hip centre of rotation (COR) on postoperative dislocation using a CT-based 3D model, as well as other potential risk factors for dislocation.

Aims

The aims of this study were to characterize the incidence and risk factors associated with stress fractures following periacetabular osteotomy, and to determine their effect on osteotomy union.

Between 1980 and 2000, 63 support rings were used in the management of acetabular deficiency in a series of 60 patients, with a mean follow-up of 8.75 years (2 months to 23.8 years). There was a minimum five-year follow-up for successful reconstructions. The indication for revision surgery was aseptic loosening in 30 cases and infection in 33. All cases were Paprosky III defects; IIIA in 33 patients (52.4%) and IIIB in 30 (47.6%), including four with pelvic dissociation. A total of 26 patients (43.3%) have died since surgery, and 34 (56.7%) remain under clinical review. With acetabular revision for infection or aseptic loosening as the definition of failure, we report success in 53 (84%) of the reconstructions. A total of 12 failures (19%) required further surgery, four (6.3%) for aseptic loosening of the acetabular construct, six (9.5%) for recurrent infection and two (3.2%) for recurrent dislocation requiring captive components. Complications, seen in 11 patients (18.3%), included six femoral or sciatic neuropraxias which all resolved, one grade III heterotopic ossification, one on-table acetabular revision for instability, and three early post-operative dislocations managed by manipulation under anaesthesia, with no further instability. We recommend support rings and morcellised bone graft for significant acetabular bone deficiency that cannot be reconstructed using mesh

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI.

Cite this article: Bone Joint J 2022;104-B(5):532–540.

Aims

This study aimed to use intraoperative free electromyography to examine how the placement of a retractor at different positions along the anterior acetabular wall may affect the femoral nerve during total hip arthroplasty (THA) when undertaken using the direct anterior approach (THA-DAA).

Aims

The aims of this study were to develop an in vivo model of periprosthetic joint infection (PJI) in cemented hip hemiarthroplasty, and to monitor infection and biofilm formation in real-time.

Aims

Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically.

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management.

Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury.

This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients.

Cite this article: Bone Joint J 2020;102-B(10):1281–1288.

Aims

There is an increased risk of dislocation of the hip after the resection of a periacetabular tumour and endoprosthetic reconstruction of the defect in the hemipelvis. The aim of this study was to determine the rate and timing of dislocation and to identify its risk factors.

Aims

Injury to the lateral femoral cutaneous nerve (LFCN) is one of the known complications after periacetabular osteotomy (PAO) performed using the anterior approach, reported to occur in between 1.5% and 65% of cases. In this study, we performed a prospective study on the incidence of LFCN injury as well as its clinical outcomes based on the Harris Hip Score (HHS), Short-Form 36 Health Survey (SF-36), and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ).

Aims

We have previously reported cryoablation-assisted joint-sparing surgery for osteosarcoma with epiphyseal involvement. However, it is not clear whether this is a comparable alternative to conventional joint arthroplasty in terms of oncological and functional outcomes.

A case of bilateral myositis ossificans in the biceps femoris muscles causing a sciatic nerve palsy on the left side is described. Complete recovery of the sciatic nerve followed excision of the mass of ectopic bone. It is postulated that the patient's hobby of weight-lifting caused the ossification

The straight leg raising test and the femoral nerve stretch test exert traction on the sciatic and femoral nerve, and the lumbosacral plexus and roots. In 40 patients with a suspected L4/5 disc protrusion, ipsilateral sciatica was induced by the femoral nerve stretch test. We believe that this is a pathognomonic sign of a lateral protrusion at L4/5 level

A primary hydatid cyst in the pelvis is rare, and usually presents with pressure symptoms affecting the adjacent abdominal organs. We describe such a cyst which protruded through the sciatic notch and presented as a gluteal swelling with a foot drop due to compression of the lumbosacral nerve roots. Surgical excision and postoperative treatment with albendazole for six weeks were effective in controlling the disease and preventing recurrence

1. A method of constricting sciatic nerves of rats was devised which produced lesions resembling macroscopically and electromyographically those of carpal tunnel and related syndromes. 2. The nerves became swollen and hyperaemic proximal and distal to the constriction. The swellings were largely caused by an accumulation of fluid between the axons, but the axons themselves were also increased in size. 3. This accumulation of fluid was an oedema secondary to a partial obstruction of the vasa nervorum

1. An operation is described for ischio-femoral extra-articular arthrodesis of the hip joint by posterior open approach, based on the techniques of Trumble and Brittain. 2. The operation has the advantages of affording adequate exposure of the sciatic nerve trunk and permitting visual control of the alignment and penetration of the chisel and graft. 3. The operation has been performed successfully without serious shock or subsequent complications in eighteen cases, mostly of tuberculosis of the hip

Endoprosthetic replacement of the pelvis is one of the most challenging types of limb-salvage surgery, with a high rate of complications. In an attempt to reduce this and build greater versatility into the reconstruction process, a new type of pelvic endoprosthesis was developed in 2003, based on the old McKee-Farrar prosthesis. This study reviews the outcomes in 27 patients who had an ice-cream cone pelvic prosthesis inserted at two different specialist bone tumour centres in the United Kingdom over the past six years. The indications for treatment included primary bone tumours in 19 patients and metastatic disease in two, and six implants were inserted following failure of a previous pelvic reconstruction. Most of the patients had a P2+P3 resection as classified by Enneking, and most had resection of the ilium above the sciatic notch. The mean age of the patients at operation was 49 years (13 to 81). Complications occurred in ten patients (37.0%), of which dislocation was the most common, affecting four patients (14.8%). A total of three patients (11.1%) developed a deep infection around the prosthesis but all were successfully controlled by early intervention and two patients (7.4%) developed a local recurrence, at the same time as widespread metastases appeared. In one patient the prosthesis was removed for severe pain. This method of treatment is still associated with high morbidity, but early results are promising. Complications are diminishing with increasing experience

Although arthroscopy of the hip is being carried out increasingly, little is known about the rate of associated complications. We describe a prospective study of 640 consecutive procedures in which a consistent technique was used. The overall complication rate was 1.6%. Complications, none of which was major or long-term, included transient palsy of the sciatic and femoral nerves, perineal injury, bleeding from the portal wounds, trochanteric bursitis and intra-articular breakage of the instrument. We believe that it is possible to undertake this operation safely using the technique described

Five vertebrae with unilateral spondylolysis are presented. The associated asymmetry of the posterior elements supports the concept of a localised form of growth deficiency. The defect is difficult to demonstrate radiologically, and is perhaps present more frequently than is recognised. It should be suspected clinically from asymmetry of the neural arch and from unilateral wedging of the vertebral body, and may be demonstrated by further radiographic examination. The clinical significance is uncertain, but one patient is presented in whom unilateral spondylolysis was associated with intermittent sciatic pain

1. Epidural abscess should be suspected in patients with lumbar and sciatic pain who have a history of staphylococcal skin infections or of diabetes. 2. The diagnosis of epidural abscess should be considered before that of herniation of a disc if the patient presents an otherwise unexplained pyrexia. The absence of radiographic changes is no bar to this diagnosis. 3. The hazards of lumbar puncture in cases of epidural abscess are obvious. 4. Early diagnosis and operation are essential to control the infective lesion and to ensure recovery of the neural lesion

1. It is possible that neonatal sciatic palsy occurs more often than is suggested by perusal of the literature: paralysis of a foot may easily be overlooked in the new-born infant; it may be regarded as a temporary paresis due to mild birth trauma; or in later months it may be attributed to poliomyelitis. 2. Eleven cases of neonatal sciatic palsy are reported. Autopsy in one suggested that the paralysis was due to direct pressure on the sciatic nerve before birth. 3. A hypothesis is advanced by which to explain how pressure on the nerve trunk may arise in utero

Aims

The proportion of arthroplasties performed in the ambulatory setting has increased considerably. However, there are concerns whether same-day discharge may increase the risk of complications. The aim of this study was to compare 90-day outcomes between inpatient arthroplasties and outpatient arthroplasties performed at an ambulatory surgery centre (ASC), and determine whether there is a learning curve associated with performing athroplasties in an ASC.

A stump neuroma is caused by the disorganised growth of axon cylinders into proliferating granulation tissue, but this is stopped by an undamaged epineural sleeve. We report experiments in the rat in which the epineural sleeve of the stump of the sciatic nerve was freed from nerve fascicles for about 5 mm and then sealed with a synthetic tissue adhesive. Neuroma formation was largely prevented in comparison with the results of other methods. This new technique has been used to treat 68 painful neuromas in 36 patients. All but three of the patients were cured or improved and none were made worse

The early management of bilateral congenital popliteal webbing in a brother and sister is described. There was no familial history of webbing, but the maternal grandfather had a hare-lip. Although the sciatic nerve is so unfavourably placed in the web, correction of the flexion deformity can apparently be carried out safely after plastic repair of the skin by Z-plasty and excision of the fibrous web cord alone, without causing a traction paralysis. These cases appear to be unique in that the patients are siblings of different sex with identical congenital abnormalities of bilateral webbing, cleft palate and fistulae of the mucous membrane of the lower lip

1. Nine patients with radiological evidence of narrowing of the lumbar spinal canal, proved at operation, are reviewed. 2. They presented with either a claudicant or a sciatic clinical picture. 3. A classification into primary or secondary spinal stenosis is described. The primary type may be due to a reduction in either the sagittal, coronal or both diameters of the spinal canal. 4. Secondary narrowing of the canal may be superimposed upon a primary anatomical abnormality or may cause narrowing in a previously normal canal. 5. The symptoms are thought to be caused by a further reduction in the size of an already narrow canal, producing traction on the nerve tissue, which is then unable to move freely

The anatomy of the autonomic sympathetic vasomotor nerve supply of bone was studied in rabbits by methods of histochemistry, and fluorescent and electron microscopy. Our observations show that the intraosseous vessels are richly supplied by adrenergic nerves. The large primary nerves are located on or about the surface of the vessel; the medium sized secondary nerves spiral around the long axis of vessels lying more deeply in the tunica adventitia; and the fine tertiary nerves form a rich plexus at the outer area of the tunica media. The tertiary nerves have various structures which probably contain neurotransmitter substance--that is, noradrenaline--and function as neuro-vasomuscular synapses. The sympathetic nerve supply of bone originates from the appropriate ganglion, and in the case of the tibial diaphysis it descends through the sciatic nerve and thereafter mainly through the medial popliteal nerve and enters the bone alongside the nutrient artery

Infection of the intervertebral space is a rare complication of operation on the disc (Ford and Key 1955). It occurred in five cases in a series of 650 operations for lumbar disc protrusion done by two of the authors of this paper--an incidence of 0-8%. Symptoms began between seven and twelve days after operation. After initial relief of the original sciatic pain, the patients developed severe back pain and muscle cramps in the legs. Straight-leg raising became much more limited than before operation. The erythrocyte sedimentation rate was raised in all cases. The diagnosis was confirmed by rescreening the Myodil, when an indentation was seen opposite the intervertebral space from which the disc had been excised. Early removal of infected material from the disc space resulted in complete relief of pain and cure of the infection

In order to investigate the functional anatomy of gluteus minimus we dissected 16 hips in fresh cadavers. The muscle originates from the external aspect of the ilium, between the anterior and inferior gluteal lines, and also at the sciatic notch from the inside of the pelvis where it protects the superior gluteal nerve and artery. It inserts anterosuperiorly into the capsule of the hip and continues to its main insertion on the greater trochanter. Based on these anatomical findings, a model was developed using plastic bones. A study of its mechanics showed that gluteus minimus acts as a flexor, an abductor and an internal or external rotator, depending on the position of the femur and which part of the muscle is active. It follows that one of its functions is to stabilise the head of the femur in the acetabulum by tightening the capsule and applying pressure on the head. Careful preservation or reattachment of the tendon of gluteus minimus during surgery on the hip is strongly recommended

1. Forty-eight cases of causalgia are reviewed and the clinical features are briefly described. 2. Multiple nerve injuries are common and the pain is often associated with all the injured nerves. In the upper limb there was always an incomplete lesion of the lower trunk or medial cord of the brachial plexus, or of the median nerve. In the lower limb there was always an incomplete lesion of the medial popliteal division of the sciatic, the medial popliteal, or the posterior tibial nerve. These nerves carry most of the sympathetic fibres to the hand and foot. With two exceptions all the nerve lesions were at or above the level of the knee or elbow. 3. Sympathectomy gives marked relief of pain in most cases of causalgia. Prompt treatment is essential to prevent the crippling deformities which follow prolonged voluntary immobilisation of the painful limb. The results of preganglionic are superior to those of postganglionic sympathectomy. 4. The possible pain pathways are discussed, and an explanation is offered for the successful results of sympathectomy in the treatment of causalgia

Nerve injury is a rare complication of total hip replacement which may be related to the exposure used for the operation. The posterior approach is traditionally associated with injury to the sciatic nerve. We have compared the incidence of nerve injury after primary total hip replacement (THR) using either a posterior or a direct lateral approach. We studied 42 consecutive patients undergoing primary total hip replacement. The surgeons used a posterior (22 patients) or direct lateral (20 patients) approach in accordance with their normal practice. The obturator, femoral, posterior tibial and common peroneal nerves were assessed clinically and electrophysiologically by electromyography (EMG) and measurement of the velocity of nerve conduction before operation and at four weeks after. All patients were free from symptoms of nerve injury after operation but five lesions were identified in four patients by the electrophysiological studies; the obturator nerve was involved in two, the femoral in one, the common peroneal in one and the posterior tibial in one. All these injuries occurred using the lateral approach. Clinical assessment alone underestimates the incidence of nerve injury complicating THR. Our study does not confirm the association of nerve injury with the posterior approach which had been described previously

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

Autogenous bone graft which has been either autoclaved or irradiated is commonly used in oriental countries as an alternative to allograft. We started to use the technique of extracorporeal irradiation of the resected specimen and reimplantation (ECIR) in 1991. There was, however, a high incidence of fracture of the irradiated bone and loss of articular cartilage. In an attempt to reduce these complications, we combined the irradiated autograft with a conventional arthroplasty. Between 1995 and 1998, 14 patients underwent limb salvage by this method. Seven had an osteosarcoma, two bony metastases, three a chondrosarcoma, one a malignant fibrous histiocytoma, and one a leiomyosarcoma. Ten tumours were located in the proximal femur, two in the proximal humerus, and two in the distal femur. One patient who had a solitary metastasis in the proximal part of the left femur died from lung metastases 13 months after operation. The remaining 13 patients were alive and without evidence of local recurrence or distant metastases at a mean follow-up of 43 months (28 to 72). Postoperative palsy of the sciatic nerve occurred in one patient, but no complications such as wound infection, fracture, or nonunion were seen. All host-irradiated bone junctions healed uneventfully within eight months. Using the Enneking functional evaluation system, the mean postoperative score for all 14 patients was 80% (57 to 93). The use of irradiated autograft prosthesis composites reduces the complications of ECIR and gives good functional results. It may be a good alternative in limb-salvage surgery, especially in countries where it is difficult to obtain allografts

Aims

To validate the Sydney Hamstring Origin Rupture Evaluation (SHORE), a hamstring-specific clinical assessment tool to evaluate patient outcomes following surgical treatment.

1. One hundred patients with dislocation of the hip joint have been reviewed, many having been re-examined at intervals ranging from two to five years after injury. 2. There were forty-six simple dislocations, forty-three dislocations with fracture of the acetabular rim, seven dislocations with fracture of the acetabular floor, and five dislocations with fracture of the femoral head. 3. Complete recovery, as judged by clinical and radiographic examination, was observed in 76 per cent. of simple dislocations, 63 per cent. of dislocations with fracture of the acetabular rim, and 40 per cent. of dislocations with fracture of the femoral head; in no case of dislocation with fracture of the acetabular floor was recovery complete. 4. Only in one case did myositis ossificans develop, and that was the only case treated by "massage and movements" throughout the first ten weeks after injury. 5. Avascular necrosis of the femoral head was recognised in a smaller proportion of patients than had been expected, but since the follow-up review extended only to four years after injury the results, in this respect, are unreliable. The incidence of this complication after injury to the hip joint cannot be assessed unless the follow-up period is at least five to ten years. 6. Early traumatic arthritis developed in 26 per cent. of patients—in 15 per cent. of simple dislocations, 25 per cent. of dislocations with fracture of the acetabular margin, 60 per cent. of dislocations with fracture of the femoral head, and 100 per cent. of dislocations with fracture of the acetabular floor. 7. When central or posterior dislocations are accompanied by fracture of the acetabular floor, early arthrodesis is the treatment of choice. 8. Displacement of marginal acetabular fragments is usually corrected by manipulative reduction or by traction. 9. Sciatic paralysis in dislocation of the hip joint is nearly always due to damage of the nerve by a displaced acetabular fragment. In such cases, if the fragment is not replaced accurately by manipulation or traction, operative reduction is urgently indicated

Aims

Iliac wing (Type I) and iliosacral (Type I/IV) pelvic resections for a primary bone tumour create a large segmental defect in the pelvic ring. The management of this defect is controversial as the surgeon may choose to reconstruct it or not. When no reconstruction is undertaken, the residual ilium collapses back onto the remaining sacrum forming an iliosacral pseudarthrosis. The aim of this study was to evaluate the long-term oncological outcome, complications, and functional outcome after pelvic resection without reconstruction.

1. A review of 204 cases of prolapsed intervertebral disc treated by the author by operation ten to twenty-five years before is presented. Injury was an etiological factor in only 14 per cent. 2. The decision to operate should be made after a clearly defined and controlled, but limited, period of closed treatment. The patients should not have to wait for operation. Treatment by closed methods should not be continued in the absence of detectable signs of improvement. Continuation under such circumstances delays recovery from paralysis, prolongs convalescence and delays return to work. Persistence of paraesthesia and numbness are other probable consequences of such delay. 3. A central disc prolapse is an indication for urgent operation if persistent sphincter disturbance or incomplete bladder evacuation is to be avoided. 4. A recurrence rate of sciatica less frequent than that associated with treatment by closed methods is noted in this and other reported series. True recurrence, as opposed to a prolapse at another level, is rare and is most probably due to continuation of the biochemical process of degeneration leading to further sequestration of disc tissue. On the other hand, the altered spinal mechanics, particularly local rigidity resulting from enucleation of a deranged intervertebral disc, may predispose to prolapse at a higher level or may themselves be the cause of symptoms of "recurrence". 5. Operation gives early and lasting relief of sciatic pain, reduces the need for the subsequent use of a corset and assists the patient to an early return to work. 6. Operation does not affect the decision to change work. This is decided by the length of history before operation and the amount of disc degeneration; and the need to change work is the same whether the patient is treated by closed means or by operation. 7. Apart from simple back raising exercises to strengthen the spinal extensor muscles, no physiotherapy need be given because it is not likely to improve the prognosis. 8. Backache is the most frequent disability after operation (17 per cent) and is related to the degree of degenerative change present before and after operation. Injury precipitated the onset of backache in three cases. Operation does not by itself produce backache. The amount of bone removed has no demonstrable effect on the late results of operation, nor on the subsequent development of degenerative changes. 9. Enucleation of the nucleus is not followed by fibrous ankylosis across the intervertebral space

Aims

Survival rates and local control after resection of a sarcoma of the pelvis compare poorly to those of the limbs and have a high incidence of complications. The outcome for patients who need a hindquarter amputation (HQA) to treat a pelvic sarcoma is poor. Our aim was to evaluate the patient, tumour, and reconstructive factors that affect the survival of the patients who undergo HQA for primary or recurrent pelvic sarcoma.

Aims

Custom flange acetabular components (CFACs) are a patient-specific option for addressing large acetabular defects at revision total hip arthroplasty (THA), but patient and implant characteristics that affect survivorship remain unknown. This study aimed to identify patient and design factors related to survivorship.

Aims

Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF.

Aims

Although good clinical outcomes have been reported for monolithic tapered, fluted, titanium stems (TFTS), early results showed high rates of subsidence. Advances in stem design may mitigate these concerns. This study reports on the use of a current monolithic TFTS for a variety of indications.

Aims

Osteolysis, secondary to local and systemic physiological effects, is a major challenge in total hip arthroplasty (THA). While osteolytic defects are commonly observed in long-term follow-up, how such lesions alter the distribution of stress is unclear. The aim of this study was to quantitatively describe the biomechanical implication of such lesions by performing subject-specific finite-element (FE) analysis on patients with osteolysis after THA.

Aims

While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA.

Nerve palsy is a well-described complication following total hip arthroplasty, but is highly distressing and disabling. A nerve palsy may cause difficulty with the post-operative rehabilitation, and overall mobility of the patient. Nerve palsy may result from compression and tension to the affected nerve(s) during the course of the operation via surgical manipulation and retractor placement, tension from limb lengthening or compression from post-operative hematoma. In the literature, hip dysplasia, lengthening of the leg, the use of an uncemented femoral component, and female gender are associated with a greater risk of nerve palsy. We examined our experience at a high-volume, tertiary care referral centre, and found an overall incidence of 0.3% out of 39 056 primary hip arthroplasties. Risk factors found to be associated with the incidence of nerve palsy at our institution included the presence of spinal stenosis or lumbar disc disease, age younger than 50, and smoking. If a nerve palsy is diagnosed, imaging is mandatory and surgical evacuation or compressive haematomas may be beneficial. As palsies are slow to recover, supportive care such as bracing, therapy, and reassurance are the mainstays of treatment.

Cite this article: Bone Joint J 2017;99-B(1 Supple A):46–9.

Aims

The aim of this study was to evaluate the long-term clinical and radiographic outcomes of the Birmingham Interlocking Pelvic Osteotomy (BIPO).