The primary aim of this study was to define and quantify three
new measurements to indicate the position of the greater trochanter.
Secondary aims were to define ‘functional antetorsion’ as it relates
to abductor function in populations both with and without torsional
abnormality. Three new measurements, functional antetorsion, posterior tilt,
and posterior translation of the greater trochanter, were assessed
from 61 CT scans of cadaveric femurs, and their reliability determined.
These measurements and their relationships were also evaluated in
three groups of patients: a control group (n = 22), a ‘high-antetorsion’ group
(n = 22) and a ‘low-antetorsion’ group (n = 10).Aims
Patients and Methods
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.
The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system. This study included 30 CO THAs versus 30 RO THAs performed by a single surgeon. Intraoperative photographs of the osseous acetabulum and periacetabular soft-tissues were obtained prior to implantation of the acetabular component, which were used to develop the proposed classification system. Interobserver and intraobserver variabilities of the proposed classification system were assessed.Aims
Methods
The gluteus minimus (GMin) and gluteus medius (GMed) have unique structural and functional segments that may be affected to varying degrees, by end-stage osteoarthritis (OA) and normal ageing. We used data from patients with end-stage OA and matched healthy controls to 1) quantify the atrophy of the GMin and GMed in the two groups and 2) describe the distinct patterns of the fatty infiltration in the different segments of the GMin and GMed in the two groups. A total of 39 patients with end-stage OA and 12 age- and sex frequency-matched healthy controls were prospectively enrolled in the study. Fatty infiltration within the different segments of the GMin and the GMed was assessed on MRI according to the semiquantitative classification system of Goutallier and normalized cross-sectional areas were measured.Aims
Methods
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. In eight cadavers, the DA approach was performed on one side,
and the DS approach on the other, a single brand of uncemented hip
prosthesis was implanted by two surgeons, considered expert in their
surgical approaches. Subsequent reflection of the gluteus maximus
allowed the extent of muscle and tendon damage to be measured and
the percentage damage to each anatomical structure to be calculated.Aims
Materials and Methods
The number of patients undergoing arthroscopic surgery of the
hip has increased significantly during the past decade. It has now
become an established technique for the treatment of many intra-
and extra-articular conditions affecting the hip. However, it has
a steep learning curve and is not without the risk of complications.
The purpose of this systematic review was to determine the prevalence
of complications during and following this procedure. Preferred Reporting Items for Systematic Reviews and Meta-Analyses
guidelines were used in designing this study. Two reviewers systematically
searched the literature for complications related to arthroscopy
of the hip. The research question and eligibility criteria were
established Aims
Materials and Methods
In this paper we propose a new classification
of neurogenic peri-articular heterotopic ossification (HO) of the
hip based on three-dimensional (3D) CT, with the aim of improving
pre-operative planning for its excision. A total of 55 patients (73 hips) with clinically significant
HO after either traumatic brain or spinal cord injury were assessed
by 3D-CT scanning, and the results compared with the intra-operative
findings. At operation, the gross pathological anatomy of the HO as identified
by 3D-CT imaging was confirmed as affecting the peri-articular hip
muscles to a greater or lesser extent. We identified seven patterns
of involvement: four basic (anterior, medial, posterior and lateral)
and three mixed (anteromedial, posterolateral and circumferential).
Excellent intra- and inter-observer agreement, with kappa values
>
0.8, confirmed the reproducibility of the classification system. We describe the different surgical approaches used to excise
the HO which were guided by the 3D-CT findings. Resection was always
successful. 3D-CT imaging, complemented in some cases by angiography, allows
the surgeon to define the 3D anatomy of the HO accurately and to
plan its surgical excision with precision. Cite this article:
The piriformis muscle is an important landmark
in the surgical anatomy of the hip, particularly the posterior approach
for total hip replacement (THR). Standard orthopaedic teaching dictates
that the tendon must be cut in to allow adequate access to the superior
part of the acetabulum and the femoral medullary canal. However,
in our experience a routine THR can be performed through a posterior
approach without sacrificing this tendon. We dissected the proximal femora of 15 cadavers in order to clarify
the morphological anatomy of the piriformis tendon. We confirmed
that the tendon attaches on the crest of the greater trochanter,
in a position superior to the trochanteric fossa, away from the
entry point for broaching the intramedullary canal during THR. The
tendon attachment site encompassed the summit and medial aspect
of the greater trochanter as well as a variable attachment to the
fibrous capsule of the hip joint. In addition we dissected seven
cadavers resecting all posterior attachments except the piriformis
muscle and tendon in order to study their relations to the hip joint,
as the joint was flexed. At flexion of 90° the piriformis muscle
lay directly posterior to the hip joint. The piriform fossa is a term used by orthopaedic surgeons to
refer the trochanteric fossa and normally has no relation to the
attachment site of the piriformis tendon. In hip flexion the piriformis
lies directly behind the hip joint and might reasonably be considered
to contribute to the stability of the joint. We conclude that the anatomy of the piriformis muscle is often
inaccurately described in the current surgical literature and terms
are used and interchanged inappropriately. Cite this article:
The direct anterior approach in total hip replacement anatomically offers the chance to minimise soft-tissue trauma because an intermuscular and internervous plane is explored. This motivated us to abandon our previously used transgluteal approach and to adopt the direct anterior approach for total hip replacement. Using MRI, we performed a retrospective comparative study of the direct anterior approach with the transgluteal approach. There were 25 patients in each group. At one year post-operatively all the patients underwent MRI of their replaced hips. A radiologist graded the changes in the soft-tissue signals in the abductor muscles. The groups were similar in terms of age, gender, body mass index, complexity of the reconstruction and absence of symptoms. Detachment of the abductor insertion, partial tears and tendonitis of gluteus medius and minimus, the presence of peri-trochanteric bursal fluid and fatty atrophy of gluteus medius and minimus were significantly less pronounced and less frequent when the direct anterior approach was used. There was no significant difference in the findings regarding tensor fascia lata between the two approaches. We conclude that use of the direct anterior approach results in a better soft-tissue response as assessed by MRI after total hip replacement. However, the impact on outcome needs to be evaluated further.
The aim of this review is to evaluate the current
available literature evidencing on peri-articular hip endoscopy
(the third compartment). A comprehensive approach has been set on
reports dealing with endoscopic surgery for recalcitrant trochanteric
bursitis, snapping hip (or coxa-saltans; external and internal),
gluteus medius and minimus tears and endoscopy (or arthroscopy)
after total hip arthroplasty. This information can be used to trigger
further research, innovation and education in extra-articular hip
endoscopy.
In patients with severe quadriplegic cerebral palsy and painful hip dislocation proximal femoral resection arthroplasty can reduce pain, but the risk of heterotopic ossification is significant. We present a surgical technique of autologous capping of the femoral stump in order to reduce this risk, using the resected femoral head as the graft. A retrospective study of 31 patients (43 hips) who had undergone proximal femoral resection arthroplasty with (29 hips) and without autologous capping (14 hips) was undertaken. Heterotopic ossification was less frequent in patients with autologous capping, and a more predictable pattern of bony overgrowth was found. For a selected group of non-ambulatory patients with long-standing painful dislocation of the hip, we recommend femoral resection arthroplasty over more complicated reconstructive operations. The risk of heterotopic ossification, which is a major disadvantage of this operation, is reduced by autologous capping.
Muscle atrophy has been demonstrated in patients suffering from osteoarthritis of the hip, but little is known about muscular recovery after total hip replacement (THR). A total of 20 patients with unilateral osteoarthritis of the hip were assessed before, six months and two years after THR. The cross-sectional area and radiological density of the muscles of the hip, thigh, calf and back were measured using CT. We hypothesised that the muscles would not recover fully after operation. After two years comparison of the limb with the THR with the healthy limb showed that there was such a reduction in the cross-sectional area in iliopsoas (7.0%; p = 0.006) and the hip adductors (8.4%, p = 0.003) and in the radiological density in gluteus maximus (10.1 Hounsfield units; p <
0.001), gluteus medius/minimus (5.6 Hounsfield units; p = 0.011), iliopsoas (3.9 Hounsfield units; p <
0.001) and the adductors (2.4 Hounsfield units; p = 0.022). Thus, there was persistent muscle atrophy in muscles acting about the hip two years after THR. We suggest that an earlier operation or a more intensive rehabilitation may reverse these changes.
We treated 26 hips (24 consecutive patients) with residual dysplasia by a technique of incomplete triple pelvic osteotomy. The mean age of the patients was 21.6 years. The mean values for the pre-operative centre-edge angle of Wiberg, the refined centre-edge angle, the acetabular angle of Sharp, the modified acetabular angle and femoral head lateralisation were 7.7°, −3.1°, 49.3°, 53.2° and 17.2 mm, respectively. After a mean follow-up of 3.3 years they were 27.0°, 13.0°, 38.9°, 44.3° and 15.9 mm, respectively (p <
0.05). The osteoarthritic grading changed adversely in one hip. The mean pre-operative and latest Harris hip scores were 74.9 and 93.0, respectively (p <
0.05). This technique provides a stable osteotomy with maintenance of the posterior column which allows early mobilisation and minimal internal fixation. The technique is not complex and requires minimal blood transfusion. The use of an image intensifier is not necessary and harvesting of a subcristal bone graft avoids post-operative complications at the donor site.
