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Effective management and control of peri- and postoperative pain in hip surgery is essential in order to minimize the use of opioids and their adverse effects. Effective regional analgesia for hip pain is made particularly challenging by the complex innervation of the hip joint. Standard regional techniques can be associated with complications, including incomplete anesthesia, hypotension, or lower limb weakness. We present the case of a 5-year-old girl with a history of infantile cerebral palsy who underwent bilateral varus derotation osteotomy and adductor tenotomy due to paralytic dislocation. She received bilateral PENG block and femoral cutaneous nerve block - a simple technique that covers all the nerves involved in the sensory innervation of the joint capsule without the need for multiple injections.

Background Postoperative acromioclavicular (AC) ligament deficiency has been identified as a common cause of failure after isolated coracoclavicular reconstruction. The two-bundle arrangement of the acromioclavicular ligament has recently been reported in histological and anatomical research. In addition, a clear structural advantage of the superoposterior bundle (SPB) over the less consistent anteroinferior bundle (AIB) was also found. However, the current understanding of the function of the acromioclavicular ligament in joint stability is based on uniaxial bone loading experiments and sequential ligament sectioning. Consequently, these rigid biomechanics models do not reproduce the coupled physiological kinematics, neither in the normal joint nor in the postoperative condition. Therefore, our goal was to build a quasi-static finite element model to study the function of the acromioclavicular ligament based on its biomechanical performance patterns using the benefits of computational models. Methods A three-dimensional bone model is reconstructed using images from a healthy shoulder. The ligament structures were modeled according to the architecture and dimensions of the bone. The kinematics conditions for the shoulder girdle were determined after the osseous axes aligned to simulate the shoulder elevation in the coronal plane and horizontal adduction. Three patterns evaluated ligament function. The peak von Mises stress values were recorded using a clock model that identified the stress distribution. In addition, the variation in length and displacement of the ligament during shoulder motion were compared using a two-tailed hypotheses test. P values Results The peak von Mises stress was consistently observed in the AIB at 2:30 in coronal elevation (4.06 MPa) and horizontal adduction (2.32 MPa). Except in the position 2:00, statistically significant higher deformations were identified in the two bundles during shoulder elevation. The highest ligament displacement was observed on the Y- and Z-axes. Conclusions The AIB has the primary role in restricting the acromioclavicular joint during shoulder motion, even though the two bundles of the AC ligament have a complementary mode of action. During horizontal adduction, the SPB appears to prevent anterior and superior translation.

To evaluate the effects of diabetes and corticosteroid injected in the joints on the shoulder motion, gait, and joint capsular properties in a rat stiffness model.A total of 27 rats were randomly distributed into 3 groups-nondiabetes group (group A), diabetes group (group B), and diabetes plus steroid injection group (group C). The diabetes model was developed by inducing hyperglycemia with a submaximal dose of streptozotocin and the stiffness model by completely immobilizing the right shoulder of each animal in all groups with sutures passed between the scapula and humeral shaft. The left shoulder was used as an untreated control in all groups. Three weeks after immobilization, the sutures were removed in all groups, and a single dose of triamcinolone acetonide (0.5 mg/kg) was injected into the glenohumeral joint in group C. After 3 weeks of free activity, range of motion (ROM) evaluation, gait analysis by stride length, and capsular area measurement were performed in all rats.Hyperglycemia was successfully induced with a mean blood glucose level of 448.9±55.9 mg/dL in group B and 431.6±17.8 mg/dL in group C, which were significantly higher than 136.5±13.4 mg/dL in group A (P.001). A significantly smaller ROM and stride length were found in the right (stiffness-induced) shoulder than that in the left (control) shoulder only in group B, and significantly larger capsular area in the right shoulder than that in the left shoulder in groups A and B (all P.05). However, in group C, there were no differences between the right and left shoulders in all measurements (all P.05). In case of the right shoulders in each group, group C showed significantly larger ROM (68° ± 11° vs. 42° ± 7°) and smaller capsular area (3934.4 ± 537.1 pixels vs. 7402.3 ± 1840.3 pixels) than group B (all P.0167).The diabetic model had a detrimental effect on the development of stiffness by thickening the joint capsule, and an intra-articular steroid injection resolved the thickened joint capsule and restored shoulder motion.

SUMMARY Surgical exposure of the anterior column, anterior wall, pelvic brim, and sacroiliac joint is accessible through the lateral window of the ilioinguinal approach. Residual attachment of the abdominal muscles and inguinal ligament to the anterior superior iliac spine (ASIS) is often a limiting factor to expanded distal and medial exposure, especially in patients with a large abdomen that hangs over the pelvis. An ASIS osteotomy has been described to improve exposure, particularly of the distal anterior wall and joint capsule, pubic ramus, and anterior quadrilateral plate. However, an ASIS osteotomy can be troublesome to reattach. In this study, we introduce a soft tissue release technique to mobilize the abdominal muscles and inguinal ligament to allow expanded surgical access to the distal anterior column/wall and sacroiliac joint and to create a working space for fracture reduction and fixation.

An 8-day-old female Shetland pony was referred to the Jeonbuk animal medical center for evaluation of bilateral hindlimb lameness. The foal had been severely lame in the both hind leg since birth. The luxation of the patella was confirmed on physical examinations. During the operation, extensive soft tissue damage and hemorrhage were observed around the medial patellar ligament. Lateral patellar luxation was surgically repaired using lateral release of the patella and medial imbrication of the joint capsule. Follow up revealed that lameness improved during postoperative period. It was concluded that patella luxation as a traumatic cause of lameness in foals can be corrected by surgical techniques successfully. Key words: Lateral patellar luxation, surgery, shetland pony, foal, stifle.

Objective: To observe the ultrasonographic characteristics of conjoined tendon repair in direct anterior approach for total hip arthroplasty (DAA-THA), and to evaluate the efficacy of musculoskeletal ultrasound in determining the healing after joint tendon repair. Methods: A total of 60 patients who required primary total hip arthroplasty in Yulin Orthopedic Hospital of Chinese and Western Medicine from July 2020 to July 2021 were selected; the patients were divided into two groups, an observation group, group A (n = 30), and a control group, group B (n = 30), according to different intraoperative methods. There was no significant difference in gender, age, and diagnosis between the two groups. Direct anterior approach was used for both the groups. For group A, the joint capsule and conjoined tendon (superior gemellus, obturator internus, and inferior gemellus) were repaired in situ, whereas for group B, only the joint capsule was repaired in situ, while the conjoined tendon was not repaired. The healing of the tendon was observed. Results: (1) in terms of diagnosis, after conjoined tendon repair, 26 cases in group A showed good tendon continuity, good tension, and a small amount of effusion echo around, three cases showed partial interruption of tendon echo, low echo, or no echo inside with insufficient structural clarity, and a case showed complete interruption; in group B, all 30 cases had continuous interruption, poor tension, tendon retraction, and thickening; the healing rate of group A’s conjoined tendon repair was 96.67%; (2) in terms of prognostic assessment, one month after the surgery, the Harris score of group A was significantly higher than that of group B (P < 0.05); however, there was no significant difference in the terms of the Harris score between the two groups 3-6 months after surgery (P > 0.05); the effective tension of conjoined tendon and the effective muscle strength of group A were significantly higher than those of group B (P < 0.05). Conclusion: Musculoskeletal ultrasound has high diagnostic value in the healing of conjoined tendon and provides dynamic clinical observation after conjoined tendon repair in DAA-THA; it is proven that DAA-THA with conjoined tendon repair on the premise of reconstructing the joint capsule can well restore its tension, enhance its muscle strength, significantly improve early joint stability and joint function, as well as facilitate the rapid recovery of patients.

Background Acromioclavicular (AC) horizontal instability is a problem affecting not only young athletic patients after a trauma to the AC joint but also older patients who have undergone distal clavicle resection. It may cause pain and poor functional outcomes unless the reconstruction technique specifically addresses the horizontal instability of the clavicle, in addition to the well-known superior instability. Methods Three cadaveric specimens underwent dissection of the AC joint capsule to determine the superior attachments of the AC joint capsule. These shoulders subsequently underwent distal clavicle resection and were loaded to a 7-kg weight in the horizontal plane. The horizontal displacement of the clavicle was measured and resection continued to the point of horizontal instability of the clavicle. Thereafter, the reverse coracoacromial ligament reconstruction technique was performed and recreation of horizontal stability assessed. Utilization of the reverse coracoacromial ligament transfer in two clinical cases will also be presented. Results The AC joint capsule is continuous with trapezius and deltoid insertions. The average distance between the articular surface and insertion of the capsule on the clavicle is 10 mm and on the acromion is 14.8 mm. Horizontal clavicular translation increased from 2.3 mm when intact to 3.3 mm with capsular transection, 8.7 mm with 5 mm clavicle resection, and finally 15 mm with a 10-mm clavicle resection. Horizontal instability of the clavicle was demonstrated with a 10-mm clavicle resection. Conclusion Horizontal instability of the clavicle is evident with distal clavicle resection of greater than 10 mm. A reverse coracoacromial ligament transfer may be a reasonable technique to address horizontal stability of the clavicle during AC joint reconstruction in the context of painful instability.

BACKGROUND Lumbar facet joint syndrome (LFJS) is a pain condition arising from lumbar facet joint diseases. Treatments of LFJS includes patient education, oral medication, bed rest, physical therapy, and procedural interventions. For some refractory cases that fail conservative therapies, dorsal ramus medial brunch radiofrequency ablation is warranted. However, as nerve fibers can regenerate, their efficacy is impermanent, and the recurrence rate is relatively high. Considering synovial impingement is a paramount pathogenesis of LFJS, in this case, we removed the culprit hyperplastic articular capsule and the articular process partially through a spinal endoscope. As the culprit hyperplastic joint capsule was excised, it is supposed to generate more prolonged efficacy and a lower recurrence rate than radiofrequency treatment. CASE SUMMARY A 40-year-old female patient was diagnosed with LFJS. She complained of low back pain and right buttock pain for half a year. The patient was placed in the prone position. After disinfection and draping, a 25-cm 18-gauge needle was inserted into the dorsal surface of the right L5 articular process. Subsequently, a guidewire, dilating tubes, and a working cannula was inserted successively. The spinal endoscope was positioned in the working cannula. Under the endoscope, the microvascular tissue, muscle tissue attached on the L5 inferior articular process and S1 superior articular process, as well as the capsule and minor portion of the inferior articular process were removed. After the joint space was clear and no bleeding points existed, the endoscope and working cannula were shifted, and the incision was sutured. After treatment, the symptoms were completely relieved. The patient was pain-free during the follow-up period of 6 mo. CONCLUSION The endoscopic partial joint capsule and articular process excision is an effective procedure for LFJS, especially for cases caused by synovial impingement.

Background: Metallosis is a syndrome of metal-induced synovitis with infiltration and accumulation of metallic debris into the periprosthetic structures, including soft and bony tissues. The debris causes a chronic inflammatory reaction due to joint instability, pain, osteolysis, implant loosening, or implant failure. The absence of a specific sign or symptom that indicates metallosis causes difficulty to diagnose. Presentation of Case: A 35-year-old female, history of primary left total hip replacement since seven years ago after avascular necrosis of the femoral head, presented with an eight-month history of left hip pain and limited range of motion. Radiograph results showed that there is no evidence of periprosthetic fracture or infection. The patient underwent a left revision total hip replacement, which revealed extensive necrotic black metal debris throughout the joint space. Discussion: Effective treatment requires a revision of total hip replacement to remove metal debris, bone graft area osteolysis, and to address the mechanical failure. The greatest possible of metallic debris during debridement is vital to avoid further osteolysis and prevent more extensive damage. Excellent clinical result was evaluated by Harris’s hip score in 18 months postoperatively. Conclusion: This case is a rare example of chronic metallosis presenting seven years following total hip replacement. Revision total hip replacement is the consensus management choice to avoid further destruction of the bone and joint capsule that can occur with metal-induced inflammation. Keywords

Massive rotator cuff tears (RCT) have traditionally been a challenging clinical problem for shoulder surgeons. A broad variety of treatment options have been proposed to address this problem, but outcomes have been as variable as the techniques themselves. Superior capsular reconstruction has been presented as a way to restore the restraining effect of the superior joint capsule and balanced force couples in massive tears of the superior rotator cuff. The purpose of this article is to propose a technical modification of the superior capsular reconstruction in large to massive RCT, and, especially in anterior L-shaped RCT, using the long head of the biceps tendon autograft to reinforce the weakest area of the anterior capsule, not as an augmentation of the rotator cuff, but as a static stabilizer of the humeral head, allowing the rotator cuff repair to heal without tension., Technique Video Video 1 With the patient in the beach chair position and into the subacromial space, a bony trough is created from the anterolateral portal in line with the bicipital groove and the mobility of the biceps tendon is checked. After medial anchor insertion a double lasso loop is made to the biceps with the first strand to facilitate the transfer to its new location. Next the suture retriever is passed under the biceps tendon to grasp the second strand for atraumatic suture. After placing the second anchor, the same process is carried out as with the medial implant, but this time we take the first strand with a simple lasso loop. Next, the sutures are tied at 30° of abduction and the stability of the biceps is checked. Finally, the tendon tenotomy is performed in the bicipital groove. Once the anterior capsular reconstruction is finished, attention is paid to the rotator cuff, and its mobility is verified; in this case we have a delaminated tear. After placing the posterior anchor of the medial row, placement of a lasso loop was performed around the free edge of the deep layer. The free end of this lasso loop suture was then passed at the muscle-tendon junction through the superficial layer. The second free end of the suture is subsequently passed through both the deep and superficial layers of the cuff. Later, the most anterior anchor of the medial row is placed, and the same procedure is carried out as with the posterior anchor. Finally, a double row repair is performed with the suture limbs of the medial row and the integrity of the repair is checked.

BACKGROUND Cadaveric models demonstrate that failure of hip capsular repair is dependent on the robustness of the repair construct. In vivo data on capsular repair construct efficacy are limited. We investigated the effect of a figure-of-8 capsular repair on hip distraction resistance relative to native and post-capsulotomy states. We hypothesized that an unrepaired capsulotomy would demonstrate increased axial distraction compared with the native state and that capsular repair would restore distraction resistance to native levels. METHODS Patients undergoing primary hip arthroscopy by a single surgeon were prospectively enrolled between March 2020 and June 2020. Prior to any instrumentation, fluoroscopic images of the operative hip were obtained at 12.5-lbs (5.7-kg) traction intervals, up to 100 lbs (45.4 kg). Anterolateral, modified anterior, and distal anterolateral portals were established. Following interportal capsulotomy, labral repair, and osteochondroplasty, fluoroscopic images were reobtained at each traction interval. Capsular repair was performed with use of a figure-of-8 suture configuration. Traction was reapplied and fluoroscopic images were again obtained. Joint distraction distance was measured at each traction interval for all 3 capsular states. Anteroposterior pelvic radiographs were utilized to scale fluoroscopic images to obtain joint space measurements in millimeters. RESULTS A total of 31 hips in 31 patients were included. Capsulotomy resulted in significant increases in distraction distance from 25 (11.3 kg) to 100 lbs of traction compared with both native and capsular repair states (all comparisons, p ≤ 0.017). Capsular repair yielded a significantly greater distraction distance compared with the native state at 37.5 lbs (17.0 kg; 5.49 versus 4.98 mm, respectively; p = 0.012) and 50 lbs (22.7 kg; 6.08 versus 5.35 mm; p < 0.001). The mean difference in distraction distance between native and capsular repair states from 25 to 100 lbs of traction was 0.01 mm. CONCLUSIONS This in vivo model demonstrates that an unrepaired interportal capsulotomy significantly increases axial distraction distance compared with the native, intact hip capsule. Performing a complete capsular closure reconstitutes resistance to axial distraction intraoperatively. Future research should evaluate the in vivo effects and associated clinical outcomes of other published capsular repair techniques and assess the durability of capsular repairs over time.

The key to preventing early knee osteoarthritis is meniscal preservation. The main functions of the meniscus are impact absorption, mechanical load transmission, lubrication, joint stability, and proprioception. Radial lesions that extend to the joint capsule are called complete radial tears. This type of injury compromises 2 of the main meniscal functions, which are impact absorption and load distribution, which is equivalent, from a biomechanical perspective, to a total meniscectomy. In the recent past, the treatment of choice for this type of injury was partial meniscectomy. However, several studies have observed progressive joint degeneration after this type of treatment. Recently, different types of meniscal sutures involving radial lesions of the meniscus have been developed. It is believed that such repairs may bring a decrease in future osteoarthritis in this patient profile. The purpose of this article is to describe the steps of continuous meniscal suture for the treatment of radial tears of the medial and lateral menisci., Technique Video Video 1 In the schematic image, we see a complete radial tear of the medial meniscus. The arrows represent the path through which the suture threads will pass through the meniscal injury. The first arrow will cross the lesion obliquely from proximal to distal and from posterior to anterior. The second arrow will cross the meniscus horizontally, from anterior to posterior The third arrow will cross the lesion obliquely from distal to proximal and posterior to anterior, and the last arrow will cross the lesion horizontally again from posterior to anterior, closing the meniscal lesion. We demonstrate the technique of continuous suture, the hourglass technique, in a bovine anatomical model performed at the arthroscopy laboratory of the National Institute of Traumatology and Orthopedics of Brazil. We make a complete radial tear in the medial meniscus body. We prepare the meniscus 4 A-II suture device with an ultra-resistant wire. Tapes are also advised to be used in this type of injury. Initially, we cross the meniscus proximal and posterior of the radial tear; by palpation, we find the exit site of the meniscal suture device. We pull the shortest suture length, which should always be positioned for the anterior side of the suture device. We fix this end with a Kelly clamp. We return with the device to the interior of the joint and position the device by passing with a suture thread obliquely on the anterior and distal surface about 5 mm from the radial tear. We cross the meniscus, easily finding the region of exit of the meniscus 4 AII. We pull the formed loop on the posterior face of the device to gain length of the wire. After this step, we increase the anterior loop of the wire so that the end of the wire passing through the interior of the device is the same as that passing through the arthroscopic portal. We return the device to the inside of the joint again and cross the lesion with a horizontally, penetrating the meniscus in the posterior and distal region of the lesion. We find the device through the extra-articular surgical approach and repeat the steps to increase the loops. We return the device to the inside of the joint and cross the lesion with the suture in an oblique way again. We enter the meniscus with the device and form a new anterior loop in the extra-articular region. After repairing the loop, we return the device to the joint and cross the lesion horizontally from anterior to posterior, penetrating the meniscus about 10 mm posterior to the radial tear. We find the device on the extra-articular surface and pull the suture out of the Meniscus 4 AII. We then remain with 2 ends of the wires and 3 loops formed. We cut each loop and through a light traction and we observe which wire connect with other. And we start the sutures, making 3 to 4 stitches on each thread. We are able to observe the complete closure of the lesion inside the joint, completing the surgical procedure.

Introduction: Hip fractures are common and disabling injuries, usually managed surgically. The most common type outside the joint capsule are trochanteric fractures, usually fixed with either sliding hip screw or intramedullary nail. Data are available in the National Hip Fracture Database (NHFD) on early failure and other major complications, but late or subtler complications may escape recording. This study sought to quantify such problems after fixation performed at 3different sites and identify their predictors. Methods: Patients with a trochanteric fracture treated at 1 of 3 sites were identified from the NHFD over a 3-year period. Any with further, related episodes of care were identified, and reasons recorded, then age- and sex-matched with those with no such episodes. Data was collected on Arbeitsgemeinschaft für Osteosynthesefragen classification, tip-apex distance, American Society of Anesthesiologists (ASA) grade, Abbreviated Mental Test Score and pre-injury mobility. The cohorts were compared, and a binomial logistic regression model used to identify predictors of problems. Results: A total of 4010 patients were entered in the NHFD across 3 sites between January 2013 and December 2015. Of these, 1260 sustained trochanteric fractures and 57 (4.5%) subsequently experienced problems leading to re-presentation. The most common was failure of fixation, occurring in 22 patients (1.7%). The binomial logistic regression model explained 47.6% of the variance in incidence of postoperative problems with ASA grade and tip-apex distance being predictive. Discussion: The incidence of re-presentation with problems was around of 5%. A failure rate of less than 2% was seen, in keeping with existing data. This study has quantified the incidence of subtler postoperative problems and identified their predictors. The type of implant used was not amongst them and patients with both implants experienced problems. Fixation continues to yield imperfect results, but patient health and robust surgical technique remain important factors in a good outcome.

Background Approximately 9% of shoulder girdle injuries involve the acromioclavicular joint (ACJ). There is no clear gold standard or consensus on surgical management of these injuries, in part perpetuated by our incomplete understanding of native ACJ biomechanics. We have therefore conducted a biomechanical study to assess the stabilizing structures of the ACJ in superior-inferior (SI) translation and anterior-posterior (AP) translation. Methods Twenty fresh frozen cadaveric specimens were prepared and mounted onto a robotic arm. The intact native joint was tested in SI translation and AP translation under a 50-N displacing force. Each specimen was retested after sectioning of its stabilizing structures in the following order: investing fascia, ACJ capsular ligaments, trapezoid ligament, and conoid ligament. Their contributions to resisting ACJ displacements were calculated. Results In the intact native ACJ, mean anterior displacement of the clavicle was 7.9 ± 4.3 mm, mean posterior displacement was 7.2 ± 2.6 mm, mean superior displacement was 5.8 ± 3.0 mm, and mean inferior displacement was 3.6 ± 2.6 mm. The conoid ligament was the primary stabilizer of superior displacement (45.6%). The ACJ capsular ligament was the primary stabilizer of inferior displacement (33.8%). The capsular ligament and conoid ligament contributed equally to anterior stability, with rates of 23% and 25.2%, respectively. The capsular ligament was the primary contributor to posterior stability (38.4%). Conclusion The conoid ligament is the primary stabilizer of superior displacement of the clavicle at the ACJ and contributes significantly to AP stability. Consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries.

The aim of this case study is to present arthroscopic treatment of recurrent hip instability after acute post-traumatic posterior hip dislocation with a fracture of the posterior acetabular wall. A male patient aged 35 suffered a dislocation of the right hip joint with a fracture of the posterior acetabular wall due to an accident. The fracture was stabilized during emergency surgery with a locking compression plate, and the patient was released home in a hip brace. Multiple dislocations of the hip joint followed with the implant being confirmed as stable. Decision was made to qualify the patient for a right hip arthroscopy. During the surgery, ligamentum teres was reconstructed using gracilis and semitendinous muscle grafts, followed by the labrum and joint capsule repair, where the surgery that stabilized the acetabular wall fracture had damaged them. There were no complications following the procedure. Short-term follow-up of 3 months demonstrates the patient has a stable hip, reduced pain and has returned to pre-injury activities.

Multidirectional shoulder instability and hyperlaxity can be treated with arthroscopic shoulder stabilization and capsular shift. In these patients, the joint capsule often becomes the weak link in terms of pullout strength and cutting through of the used sutures, which can further be compromised by reduced quality of the capsular tissue. The described delta-loop-stitch combines a loop stitch through the capsule with a 3-point-fixation to the intact labrum thus distributing the load and reducing the risk of failure of the fixation. The suture knots are directed under the joint capsule away from the articulating surfaces to reduce the risk of iatrogenic lesions of the articular cartilage. The circumferential application of the delta-loop-stitch allows a sufficient capsular shift that combines a radial and tangential shift and reduction of the overall joint volume that can be adjusted to the patient’s individual situation and the surgeon’s preference., Technique Video Video 1 Instructional video of an arthroscopic 270° circumferential capsulolabroplasty with combined axial and tangential shift for multidirectional instability in a right shoulder. The viewing portal is lateral in a right shoulder with 2 working cannulas at the anterior and posteroinferior portal. Starting at the inferior part of the glenoid, multiple delta-loop-stitches are created working from inferior to superior at the anterior and posterior part of the glenoid.

Reconstruction of lower extremity soft tissue defects is an exceptional surgical challenge, especially in multimorbid, elderly and severely ill patients with their thin and tense local soft-tissue conditions and increased perioperative risk. The distally based peroneus brevis muscle flap (DPBM), a local flap based on the muscular branches of the fibular artery, could pose a pragmatic solution. The objective of this study was to evaluate and quantify DPBM defect reconstruction in the lower leg, especially in elderly, multimorbid and severely ill patients.The DPBM as a surgical option in defect reconstruction in multimorbid, elderly, severely ill patients (inclusion criteria: at least 3 pre-existing comorbidities, patient age: at least 55 years, ASA status: at least III) was evaluated in a retrospective single-centre study from 01 April 2014 to 31 December 2019. The electronic SAP health records (EHR) were analysed according to 18 criteria, including patient details, extent of multimorbidity, defect characteristics, clinical outcome, and complications.Ten patients with a mean age of 72.6 years, a mean number of 8.5 pre-existing comorbidities and a mean ASA status of 3.1 met the inclusion criteria. The leading causes of defects, each with exposed tendons, bones, joint capsule, or joint, were chronic ulcers (n = 5) and soft tissue defects resulting from fractures (n = 3). In case of DMPB the success rate was 100% (no partial or total loss) with a short operating time (mean: 103 min) and a brief postoperative length of stay (mean: 11 d). In 2 patients (20%), DPBM surgery had to be discontinued intraoperatively and an alternative technique of defect reconstruction had to be adopted. The reasons included impaired muscle perfusion and fatty degeneration of the peroneus brevis muscle.The DPBM flap allows straightforward, fast and safe defect reconstruction in the lower extremity, particularly in elderly, multimorbid and severely ill patients at risk. In patients with inadequate peroneal brevis muscle, however, DMPB surgery should be discontinued intraoperatively and the defect reconstructed using alternative techniques.Die Rekonstruktion von Weichteildefekten der distalen unteren Extremität erweist sich insbesondere bei multimorbiden, älteren, schwer kranken Patienten aufgrund dünner und straffer lokaler Haut-Weichteil-Verhältnisse bei erhöhtem perioperativem Risiko als besondere klinische Herausforderung. Die distal gestielte M.-peroneus-brevis-Lappenplastik (DMPB) stellt hier als lokale, an Rr. musculares der A. fibularis gestielte Muskellappenplastik eine zielführende chirurgische Option dar. Ziel dieser Studie war es, den Einsatz dieser Lappenplastik zur Defektdeckung an der unteren Extremität insbesondere bei älteren, multimorbiden und schwer kranken Patienten zu evaluieren und zu quantifizieren.Mittels retrospektiver Single-Center-Studie im Untersuchungszeitraum vom 01.04.2014 bis 31.12.2019 wurde die Eignung der DMPB zur Defektdeckung an multimorbiden, älteren, schwer kranken Patienten (Einschlusskriterien: ≥ 3 Vorerkrankungen, Patientenalter: ≥ 55 Jahre, ASA-Status: ≥III) evaluiert. Im Rahmen einer SAP-Aktenanalyse wurden anhand von 18 Kriterien Patientendetails, Ausmaß der Multimorbidität, Defektbeschaffenheit, klinisches Behandlungsergebnis sowie Komplikationen untersucht.10 Patienten mit einem Durchschnittsalter von 72,6 Jahren, durchschnittlich 8,5 Vorerkrankungen und einem ASA-Status von durchschnittlich 3,1 erfüllten die Einschlusskriterien. Chronische Ulzera (n = 5) und Haut-Weichteil-Defekte als Folge von Frakturen (n = 3) jeweils mit frei liegenden Sehnen, Knochen, Gelenkkapseln oder einem frei liegenden Gelenk stellten die führenden Defektursachen dar. Wurde eine DMPB durchgeführt, so war die Erfolgsrate 100% (kein Partial- oder Totalverlust) bei zugleich kurzer OP-Dauer (durchschnittlich 103 min) und kurzem postoperativen Krankenhausaufenthalt (durchschnittlich 11 d). Bei 2 Patienten (20%) musste intraoperativ der Entschluss gegen eine DMPB gefasst und eine alternative Deckungsoption gewählt werden. Gründe hierfür waren Muskelminderperfusion oder fettige Degeneration des M. peroneus brevis.Die DMPB eignet sich insbesondere bei älteren, multimorbiden und schwer kranken Risikopatienten zur einfachen, schnellen und sicheren Defektdeckung im Bereich der unteren Extremität. Im Falle eines insuffizienten M. peroneus brevis sollte jedoch konsequent der intraoperative Entschluss gegen eine Defektdeckung durch eine DMPB und für eine alternative Deckungsoption getroffen werden.

Introduction: Frozen shoulder is condition in which there is pain and disability of shoulder joint mostly due to contraction of rotator interval capsular ligaments. Hydrodilation is procedure to dilate the contracted capsule using normal saline and local anaesthetic agent while corticosteroid therapy depicts injection of Triamcelone acetate into joint capsule to reduce inflammation and adhesions thereby reducing pain and disability.Objective: Objective of study is to compare effects of Hydrodilatation versus corticosteroids alone in intra articular shoulder joint on mobility of joint and pain in primary idiopathic frozen shoulder.Materials and Methods: 50 patients were taken in our study out of which Maximum patients are in the age group of 40-50 years i.e., 20 patients (40%) followed by 50-60 year age group i.e., 19 patients (38%), There are 31 (62%) male and 19 (38%) females in our study, Right side is more Commonly involved 33 (66%) and left side involved in 17 (34%) patients, In Corticosteroids group, at Presentation mean abduction was 21% which was improved to 61%, external rotation in neutral position was 18% which improved to 89%, external rotation in abduction was 20% which improved to 83%, In Hydrodilatation group, at Presentation mean abduction was 20% which was improved to 60%, external rotation in neutral position was 18% which improved to 86%, external rotation in abduction was 22% which improved to 82%, Average SPADI and ASES score not showing any significant difference in outcome at 1 year follow up between Hydrodilatation and corticosteroids group of patients.Conclusion: In this study, we investigated treatment effects in patients with adhesive capsulitis treated with either intra articular corticosteroid or with hydrodilatation procedure. Shoulder of the dominant hand (right side) is more commonly involved. No significant difference in the outcome as assessed with SPADI and ASES was found between both groups at 1 month, 6 month and 1 year follow up. In both groups there was significant improvement in range of motion & pain.

OBJECTIVE: The aim of this study was to immunohistochemically identify and characterize the presence of sensory nerve endings (SNEs) in pulvinar, ligamentum teres (LT), and hip joint capsule (HJC) of children with developmental dysplasia of the hip (DDH). METHODS: Pulvinar, LT, and HJC specimens were obtained from 38 hips of 36 children (31 girls, five boys; mean age=49 months; age range=18–132 months) during open reduction surgery for DDH. All specimens underwent subsequent routine tissue processing (formalin fixation and paraffin embedding). To determine tissue morphology, haematoxylin and eosin staining was used. SNEs were analyzed immunohistochemically using a mouse monoclonal antibody against S-100 Beta Protein based on the classification of Freeman and Wyke including four types of SNEs including mechanoreceptors: type I Ruffini corpuscles, type II Pacini corpuscles, type III Golgi organs, and type IVa unmyelinated free nerve endings (FNEs). Additionally, children were sorted into three groups based on their age at the time of surgery: Group 1 (age 5 years; 9 hips of 8 children). RESULTS: Although no Type I, II, or III SNEs were identified in any specimen, type IVa mechanoreceptor (FNEs) was immunohistochemically characterized in 13 (34%) pulvinar, 19 (50%) LT, and 16 (42%) HJC specimens. The total density of FNEs was 3.31±5.70)/50 mm(2) (range 0–21) in pulvinar specimens, 3.18 ± 5.92)/50 mm(2) (range 0–24) in HJC specimens, and 4.51±6.61/50 mm(2) (range 0–22) in LT specimens. Furthermore, the operated side, gender, and the number of FNEs in specimens did not differ significantly among the age groups (p>0.05 for all), and the number of FNEs was not significantly correlated with age, gender, or the operated side (p>0.05 for all). CONCLUSION: Evidence from this study revealed that pulvinar, LT, and HJC include only FNEs, which play a role in pain sensation, among mechanoreceptors. Surgical excision of these tissues may not cause a significant loss of sensory function in the hip joint of children with DDH. LEVEL OF EVIDENCE: Level II, Therapeutic Study

Aims Optimal exposure through the direct anterior approach (DAA) for total hip arthroplasty (THA) conducted on a regular operating theatre table is achieved with a standardized capsular releasing sequence in which the anterior capsule can be preserved or resected. We hypothesized that clinical outcomes and implant positioning would not be different in case a capsular sparing (CS) technique would be compared to capsular resection (CR). Methods In this prospective trial, 219 hips in 190 patients were randomized to either the CS (n = 104) or CR (n = 115) cohort. In the CS cohort, a medial based anterior flap was created and sutured back in place at the end of the procedure. The anterior capsule was resected in the CR cohort. Primary outcome was defined as the difference in patient-reported outcome measures (PROMs) after one year. PROMs (Harris Hip Score (HHS), Hip disability and Osteoarthritis Outcome Score (HOOS), and Short Form 36 Item Health Survey (SF-36)) were collected preoperatively and one year postoperatively. Radiological parameters were analyzed to assess implant positioning and implant ingrowth. Adverse events were monitored. Results At one year, there was no difference in HSS (p = 0.728), HOOS (Activity Daily Life, p = 0.347; Pain, p = 0.982; Quality of Life, p = 0.653; Sport, p = 0.994; Symptom, p = 0.459), or SF-36 (p = 0.338). Acetabular component inclination (p = 0.276) and anteversion (p = 0.392) as well as femoral component alignment (p = 0.351) were similar in both groups. There were no dislocations, readmissions, or reoperations in either group. The incidence of psoas tendinitis was six cases in the CS cohort (6%) and six cases in the CR cohort (5%) (p = 0.631). Conclusion No clinical differences were found between resection or preservation of the anterior capsule when performing a primary THA through the DAA on a regular theatre table. In case of limited visibility during the learning curve, it might be advisable to resect a part of the anterior capsule. Cite this article: Bone Joint J 2021;103-B(2):321–328.

Adhesive capsulitis of the shoulder joint is a common disease characterized by pain at the inser tional area of the deltoid muscle and decreased range of motion. The pathophysiological process involves fibrous inflammation of the capsule and intraarticular adhesion of synovial folds leading to capsular thickening and contracture. Regarding the multidirectional limitation of motion, a limitation in external rotation is especially prominent, which is related to not only global fibrosis but also to a localized tightness of the anterior capsule. Ultrasound and magnetic resonance im aging studies can be applied to rule out other structural lesions in the diagnosis of adhesive cap sulitis. Hydraulic distension of the shoulder joint capsule provides pain relief and an immediate improvement in range of motion by directly expanding the capsule along with the infusion of steroids. However, the optimal technique for hydraulic distension is still a matter of controversy, with regards to the infusion volume and rupture of the capsule. By monitoring the real-time pressure-volume profile during hydraulic distension, the largest possible fluid volume can be in fused without rupturing the capsule. The improvement in clinical outcomes is shown to be great er in capsule-preserved hydraulic distension than in capsule-ruptured distension. Moreover, re peated distension is possible, which provides additional clinical improvement. Capsule-preserved hydraulic distension with maximal volume is suggested to be an efficacious treatment option for persistent adhesive capsulitis.