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BACKGROUND: Management of acetabular defects in total joint reconstruction can be challenging. Various algorithmic approaches have been developed, with some recommending using posterosuperior acetabular buttress augments for severe defects. The superior gluteal nerve lies in close proximity to their application, and damage to it results in deterioration of hip stability and gait mechanics. There has been investigation into the relationship of the superior gluteal nerve to various anatomic points. To our knowledge, no study exists examining the relationship between the acetabular rim and the superior gluteal nerve for the application of these particular devices. METHODS: Ten adult cadaver specimens were examined. A reproducible technique in relation to the typical placement of a buttress augment was used. From a distance of 20 millimeters (mm) lateral to the greater sciatic notch, the distance from the superior gluteal nerve to the posterosuperior acetabular rim was measured. RESULTS: The average distance between the posterosuperior acetabular rim and the superior gluteal nerve was found to be 52 mm, ranging from 48 mm to 60 mm. CONCLUSION: With proprietary acetabular augments measuring up to 68 mm in length, the superior gluteal nerve could be at substantial risk with placement of these devices. Surgeons should take great care with dissection for and intraoperative placement of these devices, and particularly strive for optimized prosthetic hip stability to mitigate the risk of dislocation from nerve injury. To our knowledge, this study is the first of its kind and provides valuable anatomic and operative knowledge during these highly complex cases.
RESUMO
INTRODUCTION: Previous studies have shown that provider training and the tests performed play a role in the accuracy of diagnosis of anterior cruciate ligament (ACL) injuries. The specific aim of the current study is to determine the examiner proficiency and accuracy in performing the different proactive tests of ACL rupture before and after the induction of anesthesia prior to a definitive surgical procedure. MATERIALS AND METHODS: A case series was performed from January of 2015 through July of 2015. Two examiners were included (an experienced orthopaedic sports surgeon with more than 16 years in practice and an experienced orthopaedic physician assistant with 6 years of clinical experience in orthopaedic sports medicine). Three different physical examination tests were used before and after the induction of anesthesia to the patient: 1) Lachman test, 2) pivot shift test, and 3) Lelli test. Relevant patient demographic information such as BMI, thigh girth, and calf girth were recorded. Diagnosis of ACL rupture had been established pre-operatively. RESULTS: Thirty three patients met the inclusion criteria (males: 21 (64%), female: 12 (36%)). High percent of false negative was found with pivot shift test for both before and after anesthesia when compared to the other two tests. The Lelli test seemed to be most favorable to both the surgeon and the physician assistant with at least 67% favorable, while the pivot shift was least often felt to be the most useful test. No relationship was found for either patients' thigh or patients' calf girths with the physical examination test results for both examiners for any of the three tests (p = 0.110). CONCLUSION: The diagnostic accuracy and limitations of the various tests for ACL injury need to be understood. Clinically, it is recommended performing at least two different examinations, as each test has its own specific limitations. Level of Evidence: III- Prospective Cohort Study without blinding.
