Optimizing Tourniquet Pressure in Primary Total Knee Arthroplasty: Limb Occlusion Pressure vs Systolic Blood Pressure Method: A Randomised Controlled Study.

Background: This study aims to systematically compare the efficacy of two distinct approaches that is limb occlusion pressure (LOP) and systolic blood pressure (SBP) in determining the optimal tourniquet pressure for primary total knee arthroplasty. The overarching goal is to identify the method that yields superior outcomes in minimizing post-operative thigh pain while simultaneously reducing complications in our patient population. Methods: 311 patients scheduled for primary total knee replacement (TKR) were randomized in two groups. Group A (LOP) had 154 patients and group B had 157 patients. In group A, LOP was determined for all patients. After adding the safety margin, the tourniquet pressure was determined which was kept during the procedure. By adding 150 mm Hg to SBP in group B, the tourniquet inflation pressure was ascertained. Postoperatively, thigh pain was evaluated from day 1 to day 3 and at 6 weeks. Results: The average tourniquet pressure in group A patients having thigh circumference between 40 and 50 cm was 223.8 mm + - 19.8 mm Hg and in group B it was 262.1 + - 15.9 mm Hg (P < .01). Patients having thigh circumference between 51 and 60 cm had average tourniquet pressure of 240.07 + - 20.1 mm Hg in group A and 264.5 + - 17.4 mm Hg in group B (P < .01). The average tourniquet pressure for patients with thigh circumference more than 60 cm was 296 + /15.3 mm Hg in group A and 267.3 + /19.2 mm Hg in group B (P < 0.01). Conclusion: Tourniquet pressure determination based on the limb occlusion pressure (LOP) method provide less postoperative thigh pain and better range of motion. Graphical Abstract: Optimizing Tourniquet Pressure in Primary Total Knee Replacement: Limb Occlusion Pressure vs Systolic blood pressure method to minimize thigh pain.

A Rare Cause of Medial Thigh Pain: Does Point-of-Care Ultrasound Scan Have a Role in the Diagnosis of Obturator Hernia in the Emergency Room?

Obturator hernia describes the protrusion of the intra-abdominal viscus through the obturator foramen. It accounts for 0.05-1.4% of all hernias. We present a case of a 72-year-old female, with right-sided inner thigh pain of sudden onset who was subsequently diagnosed with an obturator hernia in the emergency room with point-of-care ultrasound (POCUS). She subsequently had laparoscopic surgery and improved without complications.

Clinical and radiological outcome of the Chimaera short nailing system in inter- and subtrochanteric fractures.

BACKGROUND: cephalomedullary devices are popular treatment for femoral intertrochanteric or subtrochanteric fractures. Various complications include post-surgical lateral thigh pain and cut-out. To prevent those complications, a new concept cephalomedullary device system was designed (Chimaera, Orthofix®). This study aimed to evaluate the clinical and radiological outcomes in patients with femoral intertrochanteric or subtrochanteric fractures treated with the proximal femoral cephalomedullary device system. METHODS: A prospective cohort study involved consecutive patients with Arbeitsgemeinschaft für Osteosynthesefragen/ Orthopaedic Trauma Association type 31-A1, 2, 3 fractures treated with the Chimaera short cephalomedullary device system from October 2016 to September 2017 at our level 1 trauma center. The Parker and Palmer mobility score and Jensen social function scores and post-surgical lateral thigh pain were assessed at 3 months post-operatively and compared to before surgery. Radiologic assessment consisted of controlling the position of the cephalic screw by using the tip-apex distance (TAD) and Cleveland zone as well as union and cut-out rates. RESULTS: We included 99 patients (79 women; 100 hips; one bilateral fracture 3 months after a first trochanteric fracture) with a mean follow-up of 2 years. The Parker and Palmer mobility score decreased by 22% at 3 months post-operatively as compared with the pre-fracture score (42/99 patients showed a return to their pre-injury level). The Jensen social function score increased by 16.5% at 3 months post-operatively as compared with the pre-fracture score (68/99 patients showed a return to their pre-injury level). No major intra-operative complication was recorded. Nine TAD scores were > 25 mm. The mean TAD was 16.5 mm (range 5-36), and the lag screw position was well positioned in most (95%) hips according to Cleveland zones. Three patients required revision surgery (one for cut-out of the lag screw, one for hip osteoarthritis and one for gluteus medius insufficiency). All patients but the one with the cut-out showed fracture union. CONCLUSION: The Chimaera short cephalomedullary device exhibited good mid-term functional and radiological outcomes.

Differences in peri-hip articular pain after total hip arthroplasty between taper wedge stem and fit-and-fill stem.

Background: Total hip arthroplasty (THA) for hip disorders helps to alleviate pain and improve active daily life. When determining the effects of medical therapy and the subsequent clinical results, patient quality of life (QOL) also needs to be assessed. Recently, patient-reported outcomes (PRO) have become important as evaluation criteria. This study aimed to evaluate patient QOL and various PRO between different types of cementless stems and to clarify the relationship between PRO and stem-cortical bone contact. Methods: The study comprised 138 consecutive patients undergoing cementless THA for hip osteoarthritis. We assessed three different types of PRO: the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), patient's joint perception, and peri-hip articular joint pain (PHAP). We measured the state of contact between femur and implant by density mapping. Results: No significant difference was noted in PRO between stem types based on the JHEQ and patient's joint perception. PHAP occurred more frequently in the patients with a taper wedge stem versus a fit-and-fill stem. In both groups, distal contact was associated with PHAP but not with JHEQ results and patient's joint perception. Conclusion: The difference in PHAP between the two stem types groups was significant, with postoperative PHAP being higher with the taper wedge stem because of the more distal contact between the taper wedge stem and femur cortical bone.

Anterior Thigh Pain Following Minimally Invasive Oblique Lateral Interbody Fusion: Multivariate Analysis from a Prospective Case Series.

Background: Oblique lateral interbody fusion (OLIF) involves the antepsoas approach and psoas major muscle (PMM) retraction to insert the interbody cage orthogonally. Therefore, OLIF is often associated with postoperative anterior thigh pain (ATP) on the approach side. However, there is limited evidence on the nature and risk factors of ATP following OLIF. Methods: Consecutive patients who planned to undergo minimally invasive OLIF and percutaneous pedicle screw instrumentation for lumbar degenerative diseases were prospectively enrolled. The visual analog scale (VAS) for ATP was recorded, and a pain map was drawn daily from the operation day to postoperative day 7 in all patients. We also prospectively collected the preoperative and intraoperative data to identify the risk factors associated with ATP. Radiologically, the total cross-sectional area (CSA), retraction length, and retraction CSA of PMM were measured from the preoperative T2-weighted axial magnetic resonance imaging scans at the L4-5 intervertebral disc level. The patients were stratified into two groups based on the experience of ATP with a VAS score of ≥ 7 at any time point. Additionally, a binary logistic regression analysis was performed to identify the associated factors. Results: The current prospective study included 92 patients (31 men, 61 women) with a mean age of 70.4 years (range, 56-86 years), who underwent OLIF at our institution. The left-side approach was used in 73 patients (79.3%), while 19 (20.7%) underwent a right-side approach. Sixty-five of the total patients (70.6%) experienced approach-side ATP to any extent during postoperative 0-7 days following OLIF. The mean pain VAS (4.4 ± 2.1) and the prevalence (57.6%) were highest at postoperative 2 days. On postoperative day 7, there were 19 patients (20.7%) who complained of residual ATP with a mean VAS of 2.6 ± 1.8. In the multivariate analysis, the PMM retraction length was significantly associated with ATP of VAS ≥ 7 (adjusted odds ratio, 2.316; p = 0.044). Conclusions: In this study, we prospectively collected and analyzed the ATP and associated factors following OLIF and identified the PMM retraction length as a potential independent risk factor for severe ATP in the immediate postoperative period following OLIF. Keywords: Anterior thigh pain, Psoas major muscle, Antepsoas, Oblique lateral interbody fusion, Genitofemoral nerve.

Lateral trochanteric bursa repair improves early hip function after posterior approach total hip arthroplasty: a prospective randomized control trial.

BACKGROUND: The trochanteric bursa (TB) is an anatomic structure, which is dissected during posterior/lateral hip approaches in Total Hip Arthroplasty (THA). Some surgeons prefer to simply resect the bursa as they believe that it may be responsible for postoperative lateral trochanteric pain (LTP). Others advocate that this tissue acts as a buffer minimizing friction between soft tissue and bone, and therefore its repair may prevent LTP after THA. AIM: The purpose of this prospective randomized controlled trial was to compare the clinical results of either resecting or repairing the TB during posterior approach THA. METHODS: Forty-two patients with primary hip osteoarthritis undergoing THA via a posterior hip approach were randomly assigned to two groups; Group A, or TB resection group and Group B, or TB repair group. All patients in both groups were evaluated postoperatively in terms of hip function, measured by the Harris Hip Score (HHS), at 6 weeks, 3 months, 6 months, and 12 months after surgery, as well as LTP during daily routine activities and lying on the operative side. RESULTS: Forty patients completed the study. Postoperative difference in terms of leg length and femoral offset was similar among the two groups (P = 0.467 and P = 0.39, respectively). At 6 weeks, patients in Group B had higher HHS (P = 0.052) and experienced less LTP when lying on the operative side (P = 0.046) but not during activities (P = 0.759). Thereafter, all functional parameters measured had comparable values in both groups. Subgroup analysis failed to identify any correlation between high offset stems and LTP. CONCLUSION: TB repair in posterior approach THA improves hip functional recovery as well as patients' ability to lie on the operative side during the early postoperative period.

Load Sharing in the Femur Using Strut Allografts: A Biomechanical Study.

Background: Femoral strut allografts are used in revision hip arthroplasty for management of bone loss associated with implant failure or periprosthetic fractures. They have also been used to treat unremitting thigh pain in well-fixed cementless femoral stems, to address the differential in structural stiffness between the stem and femoral shaft. Our study used an in vitro biomechanical model to measure the effect of placement of allografts on femoral strains, to determine their load-sharing capacity. Material and methods: Three rosette strain gauges were applied to the femoral surface of each of 6 cadaveric femurs, at the stem tip level on anterior, medial, and lateral cortices. After stem implantation, cortical strut allografts were applied to the lateral femoral shaft and secured with 4 Dall-Miles cables. A fourth gauge was placed on the midpoint of the allograft. Strains were recorded in the intact femur, then the implanted femur with and without the allograft under simulated physiologic loading in a load frame. Results: Reduction in distal femoral principal strains, between 12% and 59%, was seen in all cortices following placement of the allograft. Under axial loading, 30% of the strain in the lateral cortex was borne by the allograft. Greater reductions in strain, by as much as 59%, occurred under axial load and torque. Conclusion: The results of this biomechanical model indicate that by placement of an allograft, cortical strains can be reduced to levels approaching those in an intact femur, supporting this technique for treatment of unremitting thigh pain in well-fixed prostheses.

Selective MR neurography-guided anterior femoral cutaneous nerve blocks for diagnosing anterior thigh neuralgia: anatomy, technique, diagnostic performance, and patient-reported experiences.

OBJECTIVE: To evaluate the clinical utility of selective magnetic resonance neurography-(MRN)-guided anterior femoral cutaneous nerve (AFCN) blocks for diagnosing anterior thigh neuralgia. MATERIALS AND METHODS: Following institutional review board approval and informed consent, participants with intractable anterior thigh pain and clinically suspected AFCN neuralgia were included. AFCN blocks were performed under MRN guidance using an anterior groin approach along the medial sartorius muscle margin. Outcome variables included AFCN identification on MRN, technical success of perineural drug delivery, rate of AFCN anesthesia, complications, total procedure time, patient-reported procedural experiences, rate of positive diagnostic AFCN blocks, and positive subsequent treatment rate. RESULTS: Eighteen MRN-guided AFCN blocks (six unilateral and six bilateral blocks) were performed in 12 participants (6 women; age, 49 (30-65) years). Successful MRN identified the AFCN, successful perineural drug delivery, and AFCN anesthesia was achieved in all thighs. No complications occurred. The total procedure time was 19 (10-28) min. Patient satisfaction and experience were high without adverse MRI effects. AFCN blocks identified the AFCN as the symptom generator in 16/18 (89%) cases, followed by 14/16 (88%) successful treatments. CONCLUSION: Our results suggest that selective MR neurography-guided AFCN blocks effectively diagnose anterior femoral cutaneous neuralgia and are well-tolerated.

Do Cementless Short Tapered Stems Reduce the Incidence of Thigh Pain After Hip Arthroplasty? Systematic Review and Meta-Analysis.

BACKGROUND: The purpose of this study was to determine whether short tapered stems reduce the rate of thigh pain through a systematic review and meta-analysis of comparative studies between short tapered stems and standard-length tapered stems. METHODS: We conducted a meta-analysis of comparative studies: 1) retrospective studies and 2) randomized controlled trials (RCTs), on 2 stem designs: short tapered stem versus standard-length tapered stem. Studies were selected by means of the following criteria: 1) study design: retrospective comparative studies, prospective comparative studies, RCTs; 2) study population: patients with total hip arthroplasty or hemiarthroplasty for hip disease or hip fracture; 3) intervention: short tapered stem and standard tapered stem; and 4) outcomes; thigh pain, other clinical results. RESULTS: Among the 250 articles that were identified at the initial search, 6 studies, 4 RCTs and 2 retrospective comparative studies, were included in this meta-analysis. In the analysis of retrospective studies, the short tapered stem reduced the risk of thigh pain compared to the standard tapered stem (risk ratio [RR] = 0.13; 95% confidence interval [CI], 0.02-0.09; Z = -2.07; P = 0.039). However, in the analysis of RCTs, the incidence of thigh pain was similar between the two stem designs (RR = 1.21; 95% CI, 0.76-1.93; Z = 0.82; P = 0.410). Overall meta-analysis including all studies showed that the short tapered stem did not reduce the incidence of thigh pain compared to the standard-length tapered stem (RR = 0.91; 95% CI, 0.59-1.40; Z = -0.44, P = 0.663). CONCLUSIONS: We did not find a significant difference in the incidence of thigh pain between short tapered stem and standard tapered stem in hip arthroplasty. TRIAL REGISTRATION: PROSPERO Identifier: CRD42021231240.

Comparison of short-stem versus conventional stem for hip arthroplasty in patients younger than 60 years: 7-14 years follow-up.

PURPOSE: Short-stem prostheses in hip arthroplasty have emerged as an alternative to conventional stems, especially in younger patients. The purpose of this study was to compare functional and radiological results of a short metaphyseal fitting cementless stem versus a conventional stem implant, in patients younger than 60 years. METHODS: All patients operated from January 2006 to April 2013 were included, obtaining a minimum follow-up of 7 years. Harris Hip Score (HHS) and SF-36 (quality of life) questionnaires were applied and the presence of "thigh pain" was specifically assessed. We also compared complication rate, revision rate and average prosthesis survival. Femoral stress shielding (Gruen scale), stem subsidence, varus-valgus tilt and implant stability (Engh scale) were also compared. RESULTS: A total of 101 short-stem and 74 conventional arthroplasties were included, with an average follow-up of 9.82 (7-14) years. HHS functional score and SF-36 were excellent in both implants and no significant difference between them (p > 0.05) was found. However, "thigh pain" was present in 7 patients with conventional stems and none with short-stems (p < 0.001). The survival rate at 13 years was 99%, for both implants, and no significant differences were found between them (χ2(2) = 0.178; p = 0.673). Conventional stems had stress shielding at the greater trochanter in 72% of the cases and 43% at the calcar, being statistically superior (p < 0.001) to the stress shielding observed in the short stems. CONCLUSION: According to our results, this short-stem seems to allow preservation of bone stock, with decreased stress shielding and also a lower incidence of thigh pain compared to conventional stems. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Thigh Pain and Peri-Implant Fractures with the Use of Short Cephalo-medullary Nails: A Retrospective Study of 122 Patients.

Introduction: To assess the incidence and causes of persistent thigh pain and peri-implant fractures after union in patients of intertrochanteric fractures treated with short cephalo-medullary nails. Materials and methods: A retrospective observational study conducted at a Level 1 Trauma centre. A total of 122 patients of intertrochanteric fractures who were operated using short cephalo-medullary nails (170mm and 200mm lengths) between January 2018 to June 2019 were included in the study. Main outcomes measured were the incidence of thigh pain and peri-implant fractures. Results: Out of the 122 patients with a mean follow-up of 14.1 month, 12 patients had persistent thigh pain. Six patients had the helical blade protruding from the lateral cortex, two of them had distal tip of nail abutting on the anterior cortex and four cases had prominent proximal segment of nail which may explain the cause of their pain. Five of these patients had a combination of these findings. Two patients had pain for which no other obvious cause was found. There were no cases of peri-implant fractures in our study. Conclusion: Thigh pain associated with the use of short cephalon-medullary nails is often unrelated to nail length and can be prevented by using proper surgical technique. There seems to be no association between the use of short nails and peri-implant fractures.

Thigh Pain and Peri-Implant Fractures with the Use of Short Cephalo-medullary Nails: A Retrospective Study of 122 Patients

@#Introduction: To assess the incidence and causes of persistent thigh pain and peri-implant fractures after union in patients of intertrochanteric fractures treated with short cephalo-medullary nails. Materials and methods: A retrospective observational study conducted at a Level 1 Trauma centre. A total of 122 patients of intertrochanteric fractures who were operated using short cephalo-medullary nails (170mm and 200mm lengths) between January 2018 to June 2019 were included in the study. Main outcomes measured were the incidence of thigh pain and peri-implant fractures. Results: Out of the 122 patients with a mean follow-up of 14.1 month, 12 patients had persistent thigh pain. Six patients had the helical blade protruding from the lateral cortex, two of them had distal tip of nail abutting on the anterior cortex and four cases had prominent proximal segment of nail which may explain the cause of their pain. Five of these patients had a combination of these findings. Two patients had pain for which no other obvious cause was found. There were no cases of peri-implant fractures in our study. Conclusion: Thigh pain associated with the use of short cephalon-medullary nails is often unrelated to nail length and can be prevented by using proper surgical technique. There seems to be no association between the use of short nails and peri-implant fractures.

Delayed hematoma in gluteus medius caused by Gamma nail protrusion over the greater trochanter.

Aside from cases of mechanical complications or infection short femoral nails (SFNs) are not removed after open reduction and internal fixation (ORIF) because femoral trochanteric fractures often occur in older osteoporotic females. Occasionally, SFN removal is performed because of severe chronic hip and thigh pain after surgery. However, cases of large hematoma formation in the gluteus medius with associated severe pain have not been reported in patients after ORIF. A 58-year-old healthy woman fell and incurred a femoral trochanteric fracture at work. ORIF was performed using Gamma nail for the fracture, which was classified as AO31-1.2 according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification. The bone healed sufficiently. The patient reported chronic hip and thigh pain after ORIF, but the SFN was not removed because of concerns about further fractures. After 1 year and 8 months, she suddenly experienced severe hip and thigh pain with hip swelling, but without prior trauma. Magnetic resonance imaging (MRI) showed a large hematoma in the gluteus medius near the greater trochanter. Under general anesthesia, SFN removal was performed because of the persistent pain. After SFN removal, the chronic pain resolved without any complications, such as a femoral neck fracture. In this case, chronic hip and thigh pain and delayed hematoma may have been caused by SFN protrusion over the greater trochanter, damaging soft tissues around the gluteus medius. Thus, soft tissue injury and hematoma are possible in patients with chronic hip and thigh pain after ORIF using SFN. In using SFN for femoral trochanteric fractures, it is important to prevent protrusion of SFN over the greater trochanter. Further careful follow-up with MRI and/or ultrasonography is needed to study delayed hematoma after ORIF using SFN.

Malalignment and distal contact of short tapered stems could be associated with postoperative thigh pain in primary total hip arthroplasty.

PURPOSE: Short tapered stem placement has been extensively employed in total hip arthroplasty (THA). Suboptimal fixation tends to cause postoperative complications, such as thigh pain. However, it remains unclear whether poor seating/alignment of short tapered stems contributes to thigh pain. In this study, we retrospectively examined the factors that might be associated with thigh pain. METHODS: Medical records of 230 patients who had undergone THAs at our hospital were reviewed retrospectively. All patients received the same mediolateral (ML) short tapered femoral stems. The association between thigh pain and patients' demographics, radiographic findings, or the type of fitting of the femoral stems was investigated. RESULTS: In our cohort, 68 patients (27.8%) presented with thigh pain. Among 203 type I fit patients, 62 (30.5%) developed thigh pain, while only 6 out of 43 (12.2%) type II fit patients had thigh pain, with the differences being statistically significant (x2 = 6.706, p = 0.01). In addition, hip anteroposterior radiographs exhibited that the stem angulation (mean 2.52°), the variation in angulation (mean 1.32°), and the extent of femoral stem subsidence (mean 0.29 cm) were greater in patients with thigh pain than in their counterparts without thigh pain (all p < 0.05). CONCLUSION: Malalignment and improper seating of short tapered stems could be at least one of the reasons for post-THA thigh pain. The distal contact between the stem tip and the medial femoral cortex might result in thigh pain. Our study suggested that distal implant contact should be avoided, and stem alignment should be meticulously performed in the placement of ML short tapered femoral stems for THA.

Distal femoral cortical hypertrophy not associated with thigh pain using a short stem femoral implant.

BACKGROUND: Thigh pain following a well-fixed total hip arthroplasty (THA) remains problematic and a source of patient dissatisfaction. The purpose of this study is to evaluate if the development of distal femoral cortical hypertrophy (DFCH) is associated with postoperative thigh pain after THA. METHODS: All patients who underwent an uncomplicated primary THA via a direct anterior approach with the Taperloc Microplasty (Zimmer Biomet, Warsaw, IN, USA) implant between 2011 and 2015 were mailed a pain drawing questionnaire. Radiographs were reviewed at 1 year minimum to determine cortical thickness change from immediate post-op. Thigh pain was compared to DFCH. 293 patients were included in the study. RESULTS: Mean follow-up was 3.2 years. A total of 218 hips (74%) had cortical hypertrophy in Gruen zone 3 and 165 hips (56%) had cortical hypertrophy in Gruen zone 5. 52 hips (18%) had ⩾25% cortical hypertrophy in zone 3 and 91 hips (31%) had ⩾25% cortical hypertrophy in zone 5. A total of 44 patients (15%) reported anterior thigh pain and 43 patients (15%) reported lateral thigh pain. Development of DFCH in either Gruen zone 3 or 5 was not associated with anterior or lateral thigh pain. Stem size was positively correlated with zone 3 hypertrophy and inversely related to zone 5 hypertrophy. Thigh pain was not associated with patient age, gender, activity level or stem size. CONCLUSIONS: The development of distal femoral cortical hypertrophy after THA with a short stem implant was high, but not associated with patient-reported anterior or lateral thigh pain.

Cryoanalgesia of the anterior femoral cutaneous nerve (AFCN) for the treatment of neuropathy-mediated anterior thigh pain: anatomy and technical description.

OBJECTIVE: To describe and illustrate the magnetic resonance imaging (MRI) anatomy of the anterior femoral cutaneous nerve (AFCN) and a new technique for cryoanalgesia of the AFCN for long-term analgesic treatment of recalcitrant AFCN-mediated neuropathic pain. MATERIALS AND METHODS: Using a procedural high-resolution MRI technique, we describe the MRI anatomy of the AFCN. Three patients (mean age, 48 years; range, 41-67 years) with selective nerve block-verified recalcitrant AFCN-mediated anterior thigh pain were enrolled to undergo cryoanalgesia of the AFCN. Procedures were performed under MRI guidance using clinical wide-bore MR imaging systems and commercially available cryoablation system with MR-conditional probes. Outcome variables included technical success, clinical effectiveness including symptom relief measured on an 11-point visual analog scale, frequency of complications, and procedure time. RESULTS: Procedural MRI allowed to successfully demonstrate the course of the AFCN, accurate cryoprobe placement, and monitoring of the ice ball, which resulted in technically successful iceball growth around the AFCN in all cases. All procedures were clinically effective, with median pain intensity decreasing from 8 (7-9) before the procedure to 1 (0-2) after the procedure. The cryoanalgesia effect persisted during a 12-month follow-up period in all three patients. No major complications occurred. The average total procedure time was 98 min (range, 85-125 min). CONCLUSION: We describe the MRI anatomy of the AFCN and a new technique for cryoanalgesia of the AFCN using MRI guidance, which permits identification of the AFCN, selective targeting, and iceball monitoring to achieve long-term AFCN-mediated neuropathic pain relief.

Lesions of the abductors in the hip.

Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral thigh pain. Gluteal tendon pathology is more prevalent in women and frequency increases with age.Chronic atraumatic tears result in altered lower limb biomechanics. The chief complaint is lateral thigh pain. Clinical examination should include evaluation of muscle strength, lumbar spine, hip and fascia lata pathology. The hip lag sign and 30-second single leg stance tests are useful in diagnosing abductor insufficiency.Magnetic resonance imaging (MRI) is the gold-standard investigation to identify abductor tendon tears and evaluate the extent of muscle fatty infiltration that has predictive value on the outcome of abductor repair.Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich protein, physical and radial shockwave therapy. The limited number of available high-quality studies on treatment outcomes and limited evidence between tendinosis and partial ruptures make it difficult to provide definite conclusions regarding the best management of gluteal tendinopathy.Surgical management is indicated in complete and partial gluteal tendon tears that are unresponsive to conservative treatment.There are various open and arthroscopic surgical procedures for direct repair of abductor tendon tears. There is limited evidence concerning surgical management outcomes. Prerequisites for effective tendon suturing are neurologic integrity and limited muscle fatty infiltration. Chronic irreparable tears with limited muscle atrophy and limited fatty infiltration can be augmented with grafts. Gluteus maximus or/vastus lateralis muscle transfers are salvage reconstruction procedures for the management of chronic end-stage abductor tears with significant tendon insufficiency or gluteal atrophy. Cite this article: EFORT Open Rev 2020;5:464-476. DOI: 10.1302/2058-5241.5.190094.

Risk factors of thigh pain following total hip arthroplasty with short, tapered-wedge stem.

PURPOSE: The occurrence of thigh pain following cementless total hip arthroplasty (THA) may be dependent on multiple factors, which may differ with design of the prosthesis. Thus, this study aimed to investigate the frequency of thigh pain following cementless THA using a short, tapered-wedge stem to identify risk factors for thigh pain. METHODS: This retrospective cohort study analysed 222 joints of patients who underwent THA with a short, tapered-wedge stem. Thigh pain was evaluated using a questionnaire during each follow-up visit, and the clinical and radiographic assessments were compared. RESULTS: Thigh pain occurred in 37 patients (16.7%) during the follow-up period. The pain started two to 24 months after THA. Multivariate analysis demonstrated that higher University of California, Los Angeles, activity rating (odds ratio 7.2; 95% confidence interval (CI) 3.0-17.2); Dorr type C femoral bone shape (odds ratio 1.5; 95% CI 1.1-2.0); and stem tip-cortical bone contact (odds ratio 8.2; 95% CI 2.3-29.4) were significant risk factors of thigh pain following THA. Post-operatively, cortical hypertrophy at Gruen zone 4 was significantly found in patients with thigh pain (p value = 0.032). CONCLUSION: Risk factors of pain following THA with short, tapered-wedge stem were high activity level, Dorr type C femoral bone shape, and stem tip contacting the distal bone surface. Moreover, post-operative cortical hypertrophy at the distal stem tip significantly increased the incidence of thigh pain. Therefore, we must pay attention to the aforementioned factors to avoid post-operative thigh pain when using a short, tapered-wedge stem.

Sciatic Nerve Injury Secondary to a Gluteal Compartment Syndrome.

Gluteal compartment syndrome (GCS) is extremely rare, with a low index of suspicion among physicians, hence, it is highly overlooked. The underdiagnosis can lead to irreversible tissue ischemia and severe neurological deficits. GCS is a surgical emergency and requires immediate surgical intervention given its high morbidity and mortality. Based on the limited available literature, multiple etiologies have been postulated including traumatic and nontraumatic causes. This article presents a complex and unusual case of GCS after prolonged immobilization in an IV drug abuser who was subjected to initial missed diagnosis.

The use of density mapping in the analysis of thigh pain after total hip arthroplasty in patients with well-fixed tapered wedge stems.

PURPOSE: The mechanisms underlying thigh pain in patients with well-fixed cementless femoral components after total hip arthroplasty (THA) remains unclear. We hypothesized that the thigh pain is correlated with the initial contact state of the stem and aimed to investigate the relation between thigh pain and the initial contact state. MATERIALS AND METHODS: A total of 209 hips of 184 patients were analysed in this retrospective case-control study. The patients were divided into a thigh pain group (n = 13 hips) and a control group (without thigh pain, n = 196). Post-operative stem contact images were three-dimensionally visualized by a density mapping function using computed tomography data, which quantified the stem contact area according to Gruen zones. Thigh pain was defined as anterior or anterolateral pain upon loading at 3-month post-operatively. RESULTS: Thirteen hips (6.2%) had thigh pain; however, all the hips demonstrated stable bony ingrowth radiographically. The thigh pain group had a significantly lower contact area in zone 2 (p = 0.014). The multivariate logistic regression analysis showed that the contact area of zone 2 was negatively correlated with thigh pain [odds ratio (OR): 0.858, p = 0.018], and the canal flare index was negatively correlated with the development of thigh pain (OR: 0.336, p = 0.026). CONCLUSIONS: We identified an association between the initial contact state and post-operative thigh pain. Our data demonstrated that proper lateral contact prevents the occurrence of thigh pain in THA using a tapered wedge stem.