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Introduction The direct anterior approach (DAA) to total hip arthroplasty (THA) has a known learning curve, largely due to difficulty achieving exposure and visualization of the acetabulum and proximal femur for joint preparation. There is paucity of information on limb positioning and the degree of angulation at which the limb is positioned for adequate visualization. This study aimed to identify the mean angles of limb positioning necessary for adequate exposure when using two Mueller retractors for femoral preparation using traditional table. Materials & methods A surgeon performed a DAA THA on 11 cadaveric hemipelves, exposing the femoral canal with two simple, robust Mueller retractors. The degree of external rotation and extension of the hip was measured. Results Of the 11, the mean age was 77.6 years and mean BMI was 27.95. The mean external rotation angle was 56.5 ± 13.5°. The mean extension angle was 19.9 ± 6.6°. Discussion & conclusion The key technical step in this study incorporated a second robust Mueller retractor on the posterior aspect of the greater trochanter, providing maximum leverage to deliver the femur and achieve visibility while reducing angles of limb positioning thereby reducing complications, and ultimately lessening the learning curve.

Highlights • De Garengeot’s hernia is rare and describes a femoral hernia. • Imaging revealed typical radiological features of an inflamed appendix herniating through. • Femoral hernia contains the appendix was first described in 1731 by the Parisian surgeon Rene Jacques Croissant de Garengeot. • Femoral defect was repaired by approximation of the inguinal ligament and cooper ligament with 1.0 Ethibond on a J shaped needle., Introduction De Garengeot’s hernia is rare and describes a femoral hernia containing the vermiform appendix. Pre-operative diagnosis is at times difficult and operative intervention can prove challenging. Presentation of case We report a case of a 75-year-old woman with a swelling to the right groin for over 10 years which increased in size and became intermittently painful over a period of two weeks. Patient stated that an earlier consult was not sought as she had concerns about having to stay in hospital with the ongoing global pandemic and her significant cardiac history. Ultrasound and contrast enhanced Computed Tomography (CT) revealed typical radiological features of an inflamed appendix herniating through the femoral canal. Discussion Due to its rarity a preoperative diagnosis of a de Garengeot hernia may be difficult. There is currently no consensus to surgical approach in this setting, management is widely varied and based on the preference and expertise available during these emergency procedures. Conclusion The de Garengeot hernia though uncommon should be recognised as a differential when faced with an incarcerated femoral hernia. To the best of our knowledge, this is the first case that combines ultrasound, CT findings and a preperitoneal surgical intervention.

Aim The hydrocele of the femoral canal (Femorocele) is one of the rarest entities of femoral hernia (1). All of the reported cases were an intraoperative diagnosis and were treated with an open approach. We are reporting, the probably first femorocele diagnosed and treated laparoscopically. Material and Methods A 57-years-old female patient was presented in our outpatient clinic with pain and an unclear lump in the groin area for 6 months. The sonographic examination revealed a cystic structure in the groin area resampling Nuck’s cyst. An elective laparoscopic exploration and transabdominal preperitoneal (TAPP) repair was planned. Results A laparoscopic exploration was carried out. Intraoperatively, the cystic structure was not found in the Nuck’s Canal, but in the femoral canal as a content of a femoral hernia with some pre-peritoneal fat. By the extraction of the cyst, a gush of clear fluid was noted. After the usual preparation of the preperitoneal area, a mesh was placed in TAPP technique. Conclusions This rare variety of femoral hernias, femorocele, is commonly misdiagnosed as a strangulated hernia or Nuck’s cyst (as in this case) among other differential diagnoses (2). All published femorocele cases were treated with an open approach. As demonstrated here, such unclear cases can be laparoscopically explored and treated accordingly.

Objective Hemiarthroplasty has been identified as the treatment of choice for displaced intracapsular femoral neck fractures. A modular prosthesis is sometimes preferred for its sizing options in narrow femoral canals, despite its higher cost and no advantage in clinical outcomes. Thus, in this study, we investigated the factors affecting surgeons’ choice of prosthesis, hypothesizing that modular hemiarthroplasty is overused for narrow femoral canals compared to monoblock hip hemiarthroplasty. Methods A retrospective study of a regional level 1 trauma center was conducted. Patients who had sustained femoral neck fractures from March 2013 to December 2016 were included in this study. Inclusion criterion was modular hemiarthroplasty for a narrow femoral canal. A matched group of patients who underwent monobloc hemiarthroplasty (MH) was created through randomization. The main outcome measurements were sex, age, Dorr classification, and femoral head size. We measured the protrusion of the greater trochanter beyond the level of the lateral femoral cortex postoperatively. Modular hemiarthroplasty patients were templated on radiographs using TraumaCad for Stryker Exeter Trauma Stem (ETS®). Results In total, 533 hemiarthroplasty procedures were performed, of which 27 were modular for a narrow femoral canal. The ratio of modular to monobloc was 1:18. Average head size was 46.7 mm ± 3.6 mm for monobloc and 44.07 ± 1.5 for modular (P= 0.001). There were four malaligned stems in the monobloc group versus 14 in the modular group (P= 0.008). Unsatisfactory lateralization was noted in 18 patients (7 mm ± 2.9 mm) in the modular group compared with 8 (4.7 mm ± 3.9 mm) in the monobloc group (P= 0.029). Dorr classification was A or B in 24 patients in the modular group and 18 in the monobloc group (P = 0.006). Templating revealed that modular was not required in 25 patients. Conclusions As per our findings, it was determined that patients with a narrow femoral canal intraoperatively should not receive modular hemiarthroplasty. This is especially true for female patients with small femoral head and narrow femoral canal dimensions (Dorr A and B). They would require extensive careful planning. Surgical techniques should be explored through education intraoperatively to achieve lateralization during femoral stem preparation. This may avoid prolonged anesthetic time and achieve potential cost savings.

Cement arterio-venogram is a rare event with cement extrusion into femoral nutrient vessels. In literature it is known to be benign with no significant clinical sequelae. It is postulated that it is due to high cement implantation pressure, that results in optimal cement filling quality. All previously reported cases were female patients, and it is thought to be a female only phenomenon due to the relatively narrow femoral canal leading to higher pressures during cementation. In this case series we report 3 cases different to existing literature. All 3 patients showed a cement arterio-venogram together with bone cement implantation syndrome and hypotension intraoperatively. It was also observed that during implantation the cement was of low viscosity. We postulate low cement viscosity during implantation with pressurization is also a contributing factor to these phenomena. This case series also demonstrates the first 2 male cases, showing this the even can occur in males too. The cement arteriovenogram is located at 41%-42% femur length which is within the 'third sixth' of the length of the femur. Good cementation techniques and prevention is also highlighted in this report.

BACKGROUND We systematically reviewed the radiological outcomes of studies comparing robotic-assisted (RA-THA) and manual total hip arthroplasty (mTHA). METHODS The PubMed, Embase, and Cochrane databases were queried from 1994-2021 for articles comparing radiographic outcomes between RA-THA and mTHA cohorts. A meta-analysis was conducted whenever sufficient data was present for common outcomes. RESULTS Our analysis included 20 articles reporting on 4140 patients (RA-THA: n = 1228; mTHA: n = 2912). No differences were demonstrated for acetabular inclination or anteversion. However, RA-THA demonstrated higher rates of cup orientation within the Lewinnek and Callanan safe zones, improved femoral stem alignment, and lower global offset difference (GOD) and limb length discrepancy (all p-values

Introduction and importance A canal of Nuck cyst forms because of a patent peritoneal fold evaginating through the inguinal canal in a female patient. It is a rare diagnosis because the canal often obliterates within the first year of a female patient's life. A persistent canal of Nuck may cause indirect inguinal hernias, or form hydroceles, termed canal of Nuck cysts. Here we report the first case of a canal of Nuck cyst discovered to be evaginating through the femoral canal. Case presentation A 70-year-old female patient initially presented with a symptomatic groin mass, and a suspected inguinal hernia on pre-operative ultrasound. Intraoperatively, she was found to have a canal of Nuck cyst terminating within the femoral canal. This was successfully repaired using a modified McVay approach, and approximation of the internal inguinal ring. She performed well post-operatively with no signs of recurrence at her six-month follow-up. Clinical discussion This case report serves to highlight the canal of Nuck cyst, a rare embryologic remnant, and the first literature-reported femoral canal of Nuck cyst. We re-affirm the diagnostic unreliability of ultrasound imaging in the workup of groin hernias. Furthermore, we describe surgical techniques to repair a canal of Nuck cyst found within the femoral canal. Conclusion To the best of our knowledge, no prior literature reports a canal of Nuck cyst presenting as a femoral hernia. This rare diagnosis may be encountered in common operations and is amenable to definitive repair using traditional hernia repair techniques., Highlights • Canal of Nuck Cysts is a challenging radiological diagnosis in adults. • US (Ultrasound) scans may not be able to differentiate inguinal versus femoral Canal of Nuck Cysts. • Canal of Nuck Cysts in the femoral canal can be repaired using a modified McVay repair.

Intramedullary nails, long and short, are widely used for fixation of trochanteric femur fractures. In theory, long nails may be able to protect the entire length of the femur from a future periprosthetic fracture, providing that the nail spans the length of the entire femoral canal. The described technique for long nail insertion calls for the use of an intramedullary guidewire and depth gauge for premeasurement of the length of the canal, as well as the use of a reamer. However, compared with short nails, this technique may add cost, operating time, and blood loss. We describe a safe technique for long nail measurement that reliably spans the length of the femur while potentially reducing surgical cost, time, and blood loss. We also describe 21 cases in which the technique was applied.

Background: Retained surgical items (RSIs) are not very common in the orthopedic surgery. Here, we are reporting a case of a sponge pad left in the femoral canal for 22 years. We could not find any other reported case of retained surgical sponge in the femoral canal and that is what makes this case report unique. Case Report: The patient was a 42 year-old man who underwent surgery for the fixation of a fractured femur 22 years ago. On August 2020, this patient was seen complaining about pain at the surgical site. The assessments revealed a sponge pad retained in the femoral canal, which was removed by surgery. The union of fractured bone did not take place in the first surgery, so after 6 months a second surgery was performed and the dynamic compression plate (DCP) placed was successfully replaced with an intramedullary nail. Conclusion: The surgeon could not detect the pad 22 years ago and the patient had no significant symptom all this time. The most important take-away lesson of this paper is that retention of surgical pads could also occur with correct gauze counting, so detection and prevention protocols for RSIs must be taken seriously.

Background and objective The anterior cruciate ligament (ACL) has an essential role in preserving the function and stability of the knee joint. It acts primarily to prevent anterior tibial translation. Arthroscopic ACL reconstruction using quadrupled hamstring graft is the widely practiced modality for treating ACL injuries nowadays. The objective of this study was to assess the functional outcomes of ACL reconstruction using the transportal approach for a femoral tunnel through an accessory anteromedial portal (AAM). Materials and methods This prospective study included 35 patients who met the inclusion criteria. All patients underwent arthroscopic reconstruction of ACL using quadrupled hamstring tendon graft via transportal technique for femoral canal reaming through AAM. Patients were assessed for the functional outcome for a year using the Tegner-Lysholm knee scoring system. Results The analysis of the studied cases revealed that the mean age of the patients was around 27 years. Males were affected more than females. The left side (77.14%) was affected more than the right side (22.86%); 54.28% of patients had a history of road traffic accidents (RTAs). Preoperatively, 19 (54.28%) patients had poor and 16 (45.72%) patients had fair Tegner-Lysholm scores. After one year of follow-up, 29 (82.85%) of the patients had an excellent score as per the Tegner-Lysholm scoring system. Three patients had knee pain and thigh muscle wasting (2-3 cm), and two of them also had a sense of giving away during follow-up. Conclusion Anatomical reattachment of tendon graft for ACL reconstruction at femoral and tibial footprints is indispensable for good functional outcome and knee kinematics, and the usage of the AAM provides good visualization of femoral footprint and ease to surgeons during ACL reconstruction for making a near-accurate femoral tunnel and thereby achieving better outcomes.

Minimally invasive approach in total hip arthroplasty for the treatment of femoral neck fractures with a hemiarthroplasty.Femoral neck fractures of patients without hip osteoarthritis where the acetabulum is still intact.Lesions and infections of the skin in the approach area; hip osteoarthritis; surgeon's lack of experience with the technique.The direct anterior approach (DAA) uses the Smith-Peterson interval between the tensor fasciae latae (TFL) and the rectus and sartorius muscle. After coagulation of the ascending branches of the femoral circumflex vessels, the capsule is opened. The remaining parts of the femoral neck are removed and osteotomized if necessary. The femoral head is removed with a cork screw. Then the shaft is supported by 2 sharp retractors at the greater trochanter from cranial, and the leg is externally rotated, hyperextended, and adducted. A TFL release can be performed which we also recommend. The femoral canal is opened step by step and extended with rasps which are introduced with the double curved broach handle. Cement and the final implant are introduced and after the trial reduction also the final head. The hip is reduced, the capsule adapted and the wound closed.For this approach, there are no approach specific recommendations. Postoperative treatment depends on whether the approach was extended with muscle releases and on the type of reconstruction performed. If the approach was limited to the minimally invasive direct anterior portal, quicker rehabilitation can be expected due to the reduced muscle damage. We prefer mobilization with full weight bearing as tolerated on the next day.OPERATIONSZIEL: Der minimalinvasive Zugang ist muskelschonend, erlaubt eine rasche Operation und frühe Mobilisation.Indikationen für eine Versorgung mit einer Hemiarthroplastik sind Schenkelhalsfrakturen in Fällen ohne Koxarthrose, in denen das Azetabulum noch intakt ist.Läsionen und Infektionen der Haut im Zugangsgebiet, Koxarthrose sowie die fehlende Erfahrung des Operateurs sind Kontraindikationen.Der direkte anteriore Zugang erfolgt über das Smith-Peterson-Intervall zwischen M. tensor fasciae latae (TFL) und M. rectus bzw. M. sartorius. Unter Koagulation der aufsteigenden Äste der Vasa circumflexa femoris wird die Kapsel dargestellt und eröffnet. Die freien Schenkelhalsreste werden entfernt, und eine glatte Osteotomie wird auf der gewünschten Höhe hergestellt. Der Hüftkopf wird mit einem Korkenzieher entfernt. Der Schaft wird mit einem 2‑spitzigen Heben am Trochanter major von kranial her unterstützt und das Bein in Außenrotation, Hyperextension und Adduktion gebracht. Zur Verbesserung der Exposition des Femureingangs kann ein TFL-Release erfolgen, was die Autoren empfehlen. Danach wird der Markkanal schrittweise eröffnet und mit Raspeln, die an einem doppelt kurvierten Handgriff befestigt sind, erweitert. Zement und das finale Implantat werden eingebracht und nach Probereposition auch der definitive Kopf. Danach wird die Hüfte reponiert, die Kapsel adaptiert und die Wunde verschlossen.Für diesen Zugang gibt es keine zugangsspezifischen Empfehlungen. Die postoperative Behandlung hängt von vorgenommenen Erweiterungen des Zugangs mit Muskelablösungen und der Art der erfolgten Rekonstruktion ab. Wenn der Zugang auf das minimalinvasive direkte anteriore Portal beschränkt war, ist durch den reduzierten Muskelschaden eine deutlich raschere Rehabilitation zu erwarten. Die Autoren empfehlen Mobilisation mit voller Belastung, falls erträglich, am nächsten Tag.

Understanding the morphology of the superior aspect of the proximal femur is critical for treating femoral fracture. We assessed the correlation among the ideal insertion point of the femoral nail, femur head-neck axis, and native anteversion. One hundred patients with normal femurs were included in this study. Computed tomography (CT) images of the proximal femur superior aspect and amount of native anteversion were acquired. Generalised Procrustes analysis showed the morphological characteristics of the superior proximal femur according to native anteversion amount. Morphological characteristics were represented by 4 parameters; the correlation between parameters and native anteversion was investigated using CT data. The passing point of the line from the proximal femoral canal parallel to the native anteversion at the greater trochanter was located more posteriorly (mean 35.6%); the passing point of native anteversion was posterior in the femoral neck and head, although the line of the head-neck centre passed more anteriorly at the greater trochanter (mean 67.5%). This posterior translation was significantly associated with native anteversion amount. Morphometric geometric analysis showed that the lag screw could not pass head-neck centre from the nail inserted into proximal femoral canal. Anterior insertion of the nail was needed for positioning the lag screw centre.

A 2-year-old female European Honey buzzard (Pernis apivorus) was diagnosed with a coxofemoral luxation (craniodorsal) of the right leg. Modified toggle pin technique was performed to replace the ruptured ligament of head of femur with an artificial ligament. An anchor was tied to a monofilament-type nonabsorbable suture and placed into the buzzard's acetabular hole through the drilled femoral canal. The buzzard gradually regained full activity by 13 weeks following surgery, displaying a slight lameness but otherwise a completely normal range of motion without relapse or complication. In this specific case, the procedure was uneventful and the buzzard recovered over several months without relapse or complications. Further clinical reports including a larger number of animals are needed in order to determine whether this technique is safe and which surgical technique is more effective in birds with coxofemoral luxation.

Background:Differences in proximal femoral morphology between ethnicities may have implications on the design of cementless tapered wedge stems. This study analyses the differences in Asian and Caucasian bone morphology as well as the related fit of various cementless tapered wedge stem designs.Methods:A computed tomography database and modelling software was used to retrospectively analyse a total of 1345 femora. Ethnicity related comparisons as well as the fit of the stem designs were analysed.Results:Statistically significant differences between canal shape of Caucasian and Japanese as well as non-Japanese Asians were observed. The fit of the stems within the femoral canal was highly dependent on the respective stem shape.Conclusions:The shape differences in stem designs had a larger influence on the fit within the femoral canal than the differences in ethnicity related to bone morphology.

Introduction Controversy exists regarding the use of reamed interlocking nailing in femoral shafts with extremely narrow medullary canals (diameter ≤ 9 mm). The aims of this study were to (1) investigate the association of age and sex on femoral canal diameter in patients with a simple femoral shaft fracture and (2) compare the outcomes and complications of interlocking nailing between wide and extremely narrow intramedullary canals. Patients and methods For the purposes of this retrospective cohort study, consecutive patients with simple femoral shaft fractures were recruited between January 2009 and December 2016. The patient demographic data were analyzed. Then, fractures treated with interlocking nailing were divided into the wide group (canal diameter > 9 mm) and narrow group. The primary outcome was union rate, and the secondary outcomes were complications such as thermal necrosis, fat embolism syndrome, iatrogenic fracture, and implant failure. Results This study included 340 femoral shaft fractures. The average canal diameter was 9.97 ± 1.79 mm, with significantly wider canals in men than in women. Overall, 289 of the patients had undergone interlocking nail fixation, and a similar union rate and complications were noted between the wide canal and narrow canal groups, with the exception of the incidence of iatrogenic fracture. Conclusions Femoral shaft fractures associated with extremely narrow medullary canals are more common in women than in men. There was a similar union rate found when using interlocking nailing in a femoral shaft fracture in cases with extremely narrow and wider canals. Iatrogenic fracture is the only significant risk when using interlocking nailing in femoral shafts with extremely narrow canals.

BackgroundThe purpose of this study was to review retrospectively the primary total hip arthroplasties operated upon with the cementless Wagner Self-Locking stem in patients with type C femoral bone.MethodsTwenty-eight total hip arthroplasties were performed in 25 patients aged ≥ 60 years using a cementless Wagner Self-Locking femoral component between 2006 and 2011. According to Dorr’s criteria, all 28 femora were classified as type C bone. All patients were treated with THA using a cementless Wagner cone prosthesis. Clinical and radiologic evaluations were performed on all patients.ResultsMean follow-up period was 125 ± 10.5 months (range 96 to 156 months). Average Harris hip score pre-operatively was 46 ± 9 (range 39 to 62) and at the last follow-up was 90 ± 9 (range 83 to 98). The stem to canal fill is calculated as percentages on the operative side at three distinct levels: just below the lesser trochanter, at midstem, and 1 cm above the tip of the component on anteroposterior radiograph. The mean proximal stem-to-canal fill percentages were 97% ± 2.1%, 95% ± 3.5%, and 88% ± 2.6%, respectively (anteroposterior view) and 92% ± 2.2%, 86% ± 1.9%, and 83% ± 2.5%, respectively (lateral view). Radiographic evaluation demonstrated good osteointegration of the implants in the follow-up.ConclusionsBased on the long-straight cylindrical tapered stem design, the cementless Wagner SL stem can achieve reliable stability by close apposition of the stem and wide stovepipe femoral canal from metaphysis to diaphysis in type C bone.

Background The hydrocele of the femoral hernia sac, an extremely rare occurrence, is termed femorocele. Very few authentically reported cases of femorocele are available in the literature. The present case, diagnosed as a case of infected femorocele, was managed successfully by excision of the femorocele sac and repair of the femoral hernia. To the best of the author’s knowledge, it is the first-ever reported case of infected femorocele. Case presentation A 30-year-old lady presented with a painful 3 cm × 2 cm swelling in the right inguinal region. Though the swelling was there for 2 years, the pain and indurations started after a trivial blunt trauma over the swelling 7 days ago. The patient was febrile and mild tachycardic but had no dysuria. The oval-shaped, tense-cystic, poorly translucent, non-pulsatile, non-reducible swelling showed no cough impulse. There was also a (1.5 cm × 0.5 cm) palpable right-sided superficial inguinal lymph node. Routine blood and urine analysis reports were normal except leukocytosis (10,000/mm3) with neutrophilia. Ultrasonography of the right inguino-labial region revealed a mildly echogenic cystic swelling without any intra-abdominal communication. Exploration of the right inguinal region revealed a cystic (3 cm × 2 cm) swelling, medial to the femoral vessels, containing amber-colored fluid. The distal sac was excised, and anatomical repair of femoral canal defect was done after transfixing the neck of the femorocele sac. Fibro-fatty-collagenous tissue with mixed inflammatory cells along with a flattened mesothelial lining cell layer was found on histopathological examination. Sections from inguinal lymph node showed reactive hyperplasia. Culture of fluid from the sac revealed growth of Escherichia coli. The patient was put on anti-inflammatory drugs and antibiotics according to a sensitivity test. Patient was discharged in stable condition after 5 days. Four months after the operation, the patient is doing well, remaining asymptomatic and without any sign of recurrence. Conclusions The hydrocele of the femoral hernia sac is an extremely rare disease. When not infected, it presents a painless inguinal soft cystic swelling, commonly in women of fourth to sixth decade. This was diagnosed intraoperatively in all cases reported till date. Excision of the sac after transfixation of the neck and anatomical repair are the treatment of choice. In elderly patients, with larger defect, the mesh repair can be opted for. The femorocele may also get infected by uropathogens, and proper antibiotics should be used after a sensitivity test.

Place: United States; BACKGROUND: The knowledge of proximal femur geometry is essential in the understanding and treatment of hip pathologies. Our aim is to evaluate the range of "normal anatomical values of the proximal femur" and their relationship to age, gender, and ethnicity in a cohort of healthy population, using a 3-dimensional computed tomography automated software.METHODS: The pelvis and bilateral femora of 628 healthy individuals (394 males/234 females, mean age 61.5 ± 16.5 years, mean body mass index [BMI] 26.9 ± 5.2 kg/m(2)) including 2 ethnicities (226 Asians and 406 Caucasians) were assessed with a 3-dimensional computed tomography scan-based system using algorithm-calculated landmarks. The demographic parameters recorded were age, gender, BMI, and ethnicity. The femoral neck-shaft angle (NSA), femoral neck version, femoral offset (FO), and femoral canal flare index (fCFI) were calculated for each individual. Analyses were performed using SPSS version 22. P-values \textless.05 were considered to indicate statistical significance.RESULTS: Overall, the mean NSA was 124.7° (standard deviation [SD] 6.2), mean femoral neck version was 14.5° (SD 8.1), mean FO was 42.9 mm (SD 6.8), and mean fCFI was 3.4 (SD 0.5). Gender was associated with all parameters, with the females presenting more valgus and anteverted hips. Multivariate analysis revealed a lower NSA and fCFI and a higher FO for older individuals. Ethnicity and BMI were not associated with any parameters.CONCLUSION: Our results showed that there is a direct relationship of age and gender to the variations in the investigated proximal femur anatomical parameters in a large cohort of healthy individuals. Those important gender-based and age-based differences might advocate for more varus and lateralized component to reproduce preoperative anatomy of male and patients older than 50 years.

Anatomically, the femoral bone shows sagittal and coronal bowing. Pronounced bowing would affect femoral implant surgery accuracy, but factors associated with degrees of three-dimensional (3D) femoral bowing have not yet been identified. This study measured 3D femoral bowing and examined the correlation between 3D femoral bowing and risk factors. 3D femoral bone models of unaffected legs from 125 patients were reconstructed from computed tomography data. A trans-epicondylar axis (TEA)-based coordinate system was introduced into bone models and the reproducibility of this coordinate system was evaluated. The cross-sectional contours of the femoral canal were extracted along the vertical axis of the TEA-based coordinate system, and the angles of 3D femoral bowing were examined. The reproducibility to set the coordinate was very high. Total, sagittal, and coronal femoral bowing were 8.9 ± 1.8°, 8.7 ± 1.8°, and 0.1 ± 1.9°, respectively. There was no significant difference in the degrees of femoral bowing between males and females. Total, coronal, and sagittal femoral bowing correlated with age, height, and femoral length, but only femoral coronal bowing correlated with bone mineral density (BMD) of the femur and lumbar spine. We introduced a highly reproducible method for measuring femoral sagittal and coronal bowing by constructing a femoral 3D coordinate system. Anterior femoral bowing was the dominant direction of bowing in our Japanese cohort, whereas the degree of lateral bowing correlated with age, height, femoral length, and BMD. Our results suggest that lateral femoral bowing could increase with aging and decreasing BMD.

Objective To investigate a stem‐adjusted preparation of the femur with a kinked reamer and to determine whether this approach results in higher primary stability of a kinked stem than straight reaming of the intramedullary canal. Methods Ten cementless stems with a kinked design were implanted in synthetic femurs after preparation of the femoral canal with 2 different reamer designs (straight reaming [SR] group vs kinked reaming [KR] group). The specimens were analyzed using CT to determine the anchoring length and examined with a mechanical testing system to establish their axial stiffness, torsional stiffness, and migration distance after 10 000 gait cycles. Results The stem migration distances did not differ significantly between the groups (SR group 0.51 ± 0.16 mm vs KR group 0.36 ± 0.03 mm, P = 0.095). Only for the SR group, a correlation was found between the completely conical anchorage length and absolute stem migration (P < 0.05, R = 0.89). Regarding the torsional stiffness, no differences were observed between the study groups (SR group 6.48 ± 0.17 Nm/° vs KR group 6.52 ± 0.25 Nm/°, P = 0.398). In the KR group, significantly higher axial stiffness values were measured than in the SR group (SR group 1.68 ± 0.14 kN/mm vs KR group 2.09 ± 0.13 kN/mm, P = 0.008). Conclusions The implantation of a kinked stem after kinked conical intramedullary preparation of the proximal femur showed equivalent results regarding anchoring length, stem migration, and torsional stiffness to those for straight conical reaming. The specimens with kinked reaming showed significantly higher axial stiffness values.

We used the NaF PET scan to assess osteometabolic changes around the distal half of the femoral canal by intramedullary (IM) drill for femoral IM guiding rod insertion in total knee arthroplasty. Gentle IM rod insertion and focused attention can minimize surgical stress‐induced biological reaction of the femoral IM canal.

Reaming is an important step in long bone nailing and has a low complication rate. We report a case of a flexible reamer that got broken and incarcerated in the femoral canal during reaming in a segmental femur fracture. Routine extraction using guide wire was not possible. The incarcerated reamer was successfully extracted with the help of a jumbo cutter.

This report describes a technique and the outcome following surgical revision of a periprosthetic infected total hip replacement (THR) in a single-stage procedure with the use of antibiotic-impregnated bioabsorbable beads. A 6-year-old German Shepherd dog underwent THR 16 months previously, which subsequently became infected. The contaminated femoral and acetabular prostheses were explanted. A femoral window was used to remove the stem and cement. The endosteal surfaces of the femur and acetabulum were reamed to remove periprosthetic tissues. The femoral window was replaced and secured in position with multiple cerclage wires. A 3.5-mm locking plate was applied to the lateral aspect of the femur to prevent fracture of the proximal femoral metaphysis and trochanter. Bioabsorbable beads of calcium sulphate, impregnated with vancomycin and gentamicin, were impacted into the femoral canal followed by an uncemented femoral stem. An uncemented acetabular implant was impacted and additional antibiotic beads placed in the vicinity prior to closure. There has been no evidence of reinfection 5 years postoperatively. Analgesic and antibacterial drugs were not required during this follow-up period; activity is unrestricted with neither lameness nor pain present. Simultaneous revision of both femoral and acetabular periprosthetic infected THR implants was successfully achieved in this patient via a single-stage procedure using uncemented implants and antibiotic-impregnated bioabsorbable beads.

This report describes a clinical case of a press fit biological fixation femoral implant neck fracture (fatigue failure) and its revisions in a dog. A total hip arthroplasty revision was performed. The stem was replaced with a bigger one through a V-shape osteotomy of the proximal–lateral aspect of the femur. Stabilization was accomplished using a locking plate and two over-the-plate cerclage wires. Subsidence of the femoral stem occurred following revision and was revised with a second revision in which a collared stem was used. Two revision surgeries were necessary to have a stable functional prosthesis with successful bone integration at 7 months postoperative revaluation. Major errors encountered in this case were placement of an undersized stem and an inadequate femoral canal stability/press-fit. Fracture of a BFX femoral stem neck has not been previously reported.

In this report, we present a case of a 57-year-old man complaining of pain in both his hips. Clinically, the patient reported lameness and reduction in the range of motion of the hips. Radiographic imaging showed a very narrow medullary femoral canal, confirmed by a computed tomography scan. In consideration of the narrowness of the femoral canal and cortex thickening, and due to the rarity of the clinical case, we opted to use a custom-made prosthesis. We performed total hip arthroplasty, initially on the right side. One year later, we repeated the procedure on the left side. One year after the last surgery, the patient reported well-being and continuous improvement in walking, with no complications. This case report highlights the features and the critical issues related to this kind of surgery in patients affected by Paget's disease of the bone and the importance of custom-made implants in challenging cases.

ObjectiveThis study aimed to assess the morphology of the femoral medullary canal in subjects with developmental dysplasia of the hip (DDH) with the intent of improving the design of femoral stems in total hip arthroplasty.MethodsComputed tomography images of 56 DDH hips, which were classified into Crowe I to Crowe IV, and 30 normal hips were collected and used to reconstruct three-dimensional morphology of the femoral medullary cavity. Images of twenty-one cross sections were taken from 20 mm above the apex of the lesser trochanter to the isthmus. The morphology of femoral cavity was evaluated on each cross section for the longest canal diameter, the femoral medullary torsion angle (FMTA), and the femoral medullary roundness index (FMRI).ResultsThe Crowe IV group displayed the narrowest medullary canal in the region superior to the end of the lesser trochanter, but then gradually aligned with the medullary diameter of the other groups down to the isthmus. The FMTA along the femoral cavity increased with the severity of DDH, but the rate of variation of FMTA along the femoral canal was consistent in the DDH groups. The DDH hips generally showed a larger FMRI than the normal hips, indicating more elliptical shapes.ConclusionA femoral stem with a cone shape in the proximal femur and a cylindrical shape for the remainder down to the isthmus may benefit the subjects with severe DDH. This design could protect bone, recover excessive femoral anteversion and facilitate the implantation in the narrow medullary canal.

Introduction: Primary total hip replacement in hypo plastic proximal femur is difficult due to the presence of a small canal, soft- tissue contracture, fragility of bone, and poor femoral cement mantle when used. Intraoperatively, there could be occurrence of fracture of the femur, inadequate fit, and fill with cement less femoral component. It is found unilaterally in cases of osteonecrosis of femoral head, post- traumatic, and in sequelae of childhood septic arthritis. Case Report: A 45-year- old male patient presented to the OPD with complaints of pain in the left hip and difficulty in walking since for 4 years. The patient had a history of fever and swelling over the left hip in childhood with no treatment taken for the same. X-ray of pelvis with both hips showed deformed femoral head, short neck, narrow femoral canal (Grade 1 Dorr), and arthritic changes in acetabulum. We managed with total hip replacement using Wagner cone stem. Postoperatively, the patient is having good range of motion and having no difficulty in walking and weight- bearing. Functional outcome is good as per Harris hip score. Conclusion: Total hip replacement in hypo plastic femur with arthritis is always a challenging problem. It requires surgical expertise and proper implant selection and pre-operative planning, which prevents intraoperative and post-operative complications. Wagner cone stem is a very good option in managing this type of patients. Keywords: Unilateral hypo plastic proximal femur, childhood septic arthritis, narrow femoral canal (Grade 1 Dorr), total hip replacement, Wagner cone stem.

Background The laparoscopic totally extraperitoneal inguinal hernia repair (TEP), unlike the Lichtenstein tension-free mesh repair, allows for inspecting the femoral canal area for the presence of an occult femoral hernia. Objectives To determine the incidence of an unsuspected femoral hernia in patients undergoing TEP repair. Material and methods Data was collected prospectively from 180 patients (23 women) who underwent hernia repair, including examination of the femoral canal, between November 2017 and March 2019, and the incidence of a femoral hernia was determined. Correlations between the incidence of a femoral hernia and sex, age and the type of inguinal hernia diagnosed in the patients (indirect, direct, both indirect and direct) were assessed. Results Femoral hernias were found in 14 patients (7.77%). None of the hernias had previously been detected clinically. The incidence of a femoral hernia was higher in women (6/23, 26.07%) than in men (8/157, 5.09%). The incidence of a femoral hernia was higher in older patients: the average age of patients with a femoral hernia was 57.86 years (median: 60 years), whereas the average age of patients without a femoral hernia was 49.92 years (median: 49 years). However, the correlation was not statistically significant. No correlation was found between the incidence of a femoral hernia and the type of inguinal hernia diagnosed in the patients (direct, indirect, both indirect and direct). Conclusions The TEP repair allows for detecting and repairing an occult femoral hernia.

The CentPillar stem (Stryker Orthopaedics), an anatomical short stem, was designed to match the proximal femoral canal shape in both patients with normal hips and those with developmental dysplasia of the hip (DDH). The long-term outcomes of the CentPillar stem was examined herein.In total, 222 hips that underwent total hip arthroplasty using the CentPillar stem were analyzed. DDH was the main reason for surgery (79.3%). Implant survivorship was assessed using Kaplan-Meier analysis. For radiographic evaluation, stress shielding was assessed using the Engh classification. For functional evaluation, patients' ability to perform deep hip bending activities (sit on the floor, squat, and sit straight) was assessed.During a median follow-up of 13.1 years, 2 stem revisions were performed (aseptic loosening and late hematogenous periprosthetic infection), and the overall cumulative implant survival rate was 99.0% at 15 years. In the radiographic evaluation, grade3 stress shielding was found in only one hip. More than 80% of the patients were able to perform each of the three deep hip bending activities.Good fixation at the proximal part of the femur was obtained, and the implant survival rate of the CentPillar stem was excellent during a long-term follow-up.

Background: Femoral intramedullary canal referencing is used by most knee arthroplasty systems for distal femoral cut; to avoid the opening of the femoral canal different solutions have been presented such as navigation, patient-specific instruments (PSI) or the use of an extramedullary device. The FuZion® system is a tensor device, created to merge the two main techniques for performing a total knee arthroplasty: the ligament balancing and measured resection techniques. Our idea was to use the tensor as an extramedullary cutting guide for the distal femoral cut, based on a 90° tibial resection. Methods: A total of 110 patients were operated on with this technique. Patients were evaluated with weight-bearing long-standing X-rays, knee a-p and lateral views, validated PROMs (Oxford Knee Score, EQ-5D and EQ-VAS), the Knee Society Scoring System (KSS) and the Forgotten Joint Score (FJS). Minimum follow up was 3years (range 38–50months). Results: Complete results were available for 104 patients (5 were lost in follow up and 1 died). Significant improvements were registered for all the evaluated scores from pre-op to the final follow up. Pre-op long-standing X-rays showed 21 valgus knees (20%) with a mean HKA of 187.6° (± 3.2°), 70 varus knees (62%) with a mean 172.2° (± 3.7°) HKA and 19 neutrally aligned knees, with a mean HKA of 179.5° (0 ± 2°). The radiographic evaluation at 3months post-op showed 20 valgus knees (mean HKA 183.7° ± 1.5°), 67 varus knees (mean HKA 176.1° ± 1.8°) and 23 neutrally aligned knees with a mean HKA of 179.3° (0 ± 2°). At final follow up the survival rate was 100% for revision of the implant as the endpoint. With any reoperation as the endpoint Kaplan–Meier survival estimate showed a survival rate of 95.1% at 3years. Conclusions: This technique for performing a ligament driven alignment in total knee arthroplasty showed encouraging clinical outcomes at mid-term follow up leaving a residual deformity on the coronal plane.

In our previous studies, we were able to identify anatomical differences as a predictor for aseptic loosening following primary and revision surgery with the use of rotating hinge prosthesis. This study was performed to answer following question: can a novel radiological classification system of the distal femur be identified? A total of 200 patients who received standardized anteroposterior (AP) and lateral views of the knee joint were included in this study. On AP radiographs, we measured the distance between inner diameter of the femur at 20 cm proximally from the knee and at a point 2 cm proximally from the adductor tubercle. The ratio of the inner diameter of the femoral canal at 20 cm proximal of knee joint to the inner diameter of medullary canal at 2 cm proximal of adductor tubercle was used as a novel index ratio. Two observers blindly and independently reviewed the anteroposterior radiographs twice. Three groups of anatomical classification can be constructed for each sex according to the 25th and 75th percentiles. A higher distribution of Type C was found in female patients. The median intra-observer reliability for rater 1 was 0.995 (IQR 0.994–0.997). We had also a high inter-observer reliability with ICC of 0.997 (95% CI 0.996–0.998). The novel classification presents three different types of the knee joint for male and female patients. Type C has a wider inner diaphyseal diameter compared to Type A with a narrow inner diaphyseal diameter.

BackgroundDorr type C femoral bone exhibits a wide, stovepipe-shaped femoral canal, and thin cortices in the proximal femur. Dorr C bone combined with severe osteoporosis is an important challenge in primary hip arthroplasty. In this study, we assessed the effects of short metaphyseal fitting cementless stems on preformatted primary total hip arthroplasties in young adult osteoporotic patients with this femoral presentation.MethodsA total of 42 hip arthroplasties were performed in 35 young patients (range 20 to 36 years) using a short Tri-lock bone preservation metaphyseal-fitting cementless femoral component between 2012 and 2017. The mean age at surgery of the 27 male (33 hips) and 8 female (9 hips) patients was 27.5 years (range 20.3 to 35.8 years). The mean body mass index (BMI) was 20.2 kg/m2(range, 16.8–23.2 kg/m2). According to Dorr’s criteria, all 42 femora were classified as type C bone and all femurs suffered from severe osteoporosis (Singh index ≤ 3).ResultsThe mean follow-up period was 5.5 years (range 3.0 to 8.0 years). The clinical and functional results improved for the Harris hip score, WOMAC, and UCLA activity scores. The Harris Hip score improved from 48.0 ± 8.0 (range 38.0 to 61.0) preoperatively to 87.0 ± 9.0 (range 77.0 to 92.0) at 12 months after surgery and 91.0 ± 8.0 (range 85.0 to 98.0) at final follow-up. The preoperative UCLA activity score was 3.0 ± 0.5 points (range, 1.0–4.0 points), which significantly improved to 7.5 ± 0.7 points (range 6.0 to 8.0 points) at the final follow-up. No patient exhibited thigh pain at the final follow-up. The mean stem-to-canal fill percentages were 97% ± 2.1% (anteroposterior view at midstem). For stem alignment, 40 hips (95.2%) of the femoral stem were positioned neutrally to 3° of varus with reference to the femoral shaft axis. The remaining two were positioned at 4° varus to 4° valgus. Radiographic evaluation showed good osteointegration of the implants in follow-up.ConclusionsBased on the tapered-wedge design and proximal porous coating, the shortened tapered conventional stem can achieve reliable stability through neck filling and metaphyseal fixation, which does not depend on the isthmus hoop stress. This stem was suitable in severe osteoporotic patients with type C bones in young adults who presented with a correspondingly straightened femoral canal with a wide isthmus and thin cortex.

Purpose:. The Surgical Implant Generation Network (SIGN) intramedullary nail was designed for use in resource limited settings which often lack fluoroscopy, specialized fracture tables, and power reaming. A newer design iteration, the SIGN Fin nail, was developed to further simplify retrograde femoral nailing by making proximal interlocking screw placement unnecessary. Instead, the leading end of the Fin nail achieves stability through an interference fit within the proximal femoral canal. While the performance of the traditional SIGN nail has been reported previously, no large series has examined long-term clinical and radiographic outcomes of femoral shaft fractures treated with the SIGN Fin nail. Methods:. The SIGN online surgical database was used to identify all adult femoral shaft fractures treated with the SIGN Fin nail since its introduction. All patients with minimum 6 month clinical and radiographic follow-up were included in the analysis. Available demographic, injury, and surgical characteristics were recorded. Fracture alignment was evaluated on final follow-up radiographs using a previously validated on-screen protractor tool. Coronal and sagittal plane alignment measurements were recorded as deviation from anatomic alignment (DFAA), with units in degrees. Fracture healing was assessed on final follow-up radiographs, with union defined as any bridging callus and/or cortical remodeling across one cortex on orthogonal views. Clinical outcomes available in the database included knee range of motion (ROM) greater than 90° and weight-bearing status at final follow-up. Clinical and radiographic outcomes were then compared between patients with united and nonunited fractures. Results:. The database query identified 249 femoral shaft fractures stabilized with the Fin nail in 242 patients who had minimum 6 month clinical and radiographic follow-up. Final follow-up radiographs were performed at an average of 48 weeks postoperatively. Average coronal and sagittal plane alignment measured on final follow-up radiographs were 2.18° and 2.58°, respectively. The rate of malalignment (DFAA > 10° in either plane) at final follow-up was 6%. Two hundred twenty-nine fractures (92%) were united at final follow-up. Overall, 209 (84%) of patients achieved full weight bearing and 214 (86%) achieved knee ROM >90° at final follow-up. Compared to patients with united fractures, those with nonunion were less likely to achieve full weight bearing (20% vs 90%, P 90° (30% vs 91%, P

Malalignment is the most important risk factor for fixation failure after intertrochanteric fracture treated with a cephalomedullay nail (CMN). Malalignment continues to occur despite advances in surgical techniques.We hypothesized that small femur canal size causes intra-operative reduction loss during cephalomedullary nail insertion.A retrospective study was performed from 2014 to 2017. Patients with acute intertrochanteric fracture implanted with the same sized CMN (Stryker, Mahwah, NJ, USA, diameter: 10mm, length: 170mm, degree 130) were included. Evaluated radiographic parameters included femoral canal size, corrected neck-shaft angle, and calcar reduction.The study totally included and analyzed the data from 108 patients. Patients with smaller femoral canal size tended to have increased calcar distance according to Pearson's correlation coefficient analysis (r(106)=-0.805, p0.001). Patients with calcar mal-reduction had higher corrected neck-shaft angle post-operatively. This observed correction tended to be lost during follow up.Small femoral canal size resulted in poorer reduction quality. Reduction loss during nail insertion may be due to the whole proximal fragment instead of the superolateral femoral neck. Reaming the isthmus before nail insertion or choosing a smaller sized CMN is indicated in this patient population to prevent intra- or post-operative loss of reduction.III; retrospective study.

Objective To evaluate a thrombin gel matrix (TGM), Floseal, for the prevention of lymphocele in patients with endometrial cancer who underwent pelvic lymphadenectomy. Methods A total of 79 consecutive patients with endometrial cancer were randomly allocated to one of two groups: the TGM group and control group. After completion of the lymphadenectomy, 5 mL of Floseal was applied to the bilateral pelvic sidewalls, especially the femoral canal, obturator, and common iliac vessels areas. Computed tomography scans were obtained for lymphocele evaluation 2 months after the surgery. Results Three patients from the TGM group, and four patients from the control group were lost during follow-up, and data from 36 participants from each group were analyzed. As the primary outcome, lymphocele developed in 12 patients in both groups (33 %). There was no significant difference between the groups in terms of lymphocele and symptomatic lymphocele development. Lymphocele localization was also not different between the two groups, but the diameter of the lymphoceles detected in the TGM group was significantly greater (p = 0.021). The mean drainage days was significantly shorter in the TGM group (p = 0.015). The amount of drainage was also less in the TGM group, but the difference was not statistically significant. Conclusion Thrombin gel matrix applied to the pelvic sidewalls does not reduce the incidence of symptomatic or asymptomatic lymphoceles after pelvic lymphadenectomy in endometrial cancer. However, it can reduce the amount of drainage and the number of drainage days so it can help to shorten hospitalization.

Empty scrotum is a relatively rare entity, with few cases reported in the literature, so far; if it coexists with bilateral ectopic femoral testes, it then constitutes an extremely rare congenital abnormality. We report a case of empty scrotum revealed at the first physical examination of a neonate. The scrotum appeared empty and no testes could be palpated in the scrotum or the inguinal canal. Two solitary, oval masses were palpable laterally of each hemiscrotum, close to femoral canal and the diagnosis of bilateral femoral ectopic testes was confirmed by the consultant pediatric surgeon.

The following case report documents the clinical presentation, ultrasonographic appearance, surgical management and outcome of a horse with a traumatic tear extending from the superficial and deep inguinal rings, across the aponeurosis of the external abdominal oblique muscle and inguinal ligament, disrupting the femoral ring, vascular lacuna and peritoneum. This subsequently resulted in fluid accumulation within the femoral canal. This unusual injury and presentation gives rise to discussion of the aetiology and nomenclature that should be used to properly describe this injury.

Background: The line-to-line cementing technique is proposed to create a press-fit in the femoral canal, which is contrary to modern cementing techniques. The term ‘French paradox’ has been used to describe the acceptable results associated with this technique. It has been suggested that the quality of the mantle may not be satisfactory, predisposing to early failure and aseptic loosening. Methods: The line-to-line cementing technique, where the femoral stem was oversized by 1 size compared to the broach, was compared to the standard cementing technique using corresponding sized broaches and stems, in 6 pairs of human cadaver femora with taper-slip design C-stems. Cement pressure was measured, and cement mantle thickness was analysed. A mixed effects model with random intercepts was used to examine the relationship between thickness of mantle and cementing technique and between pressure and cementing technique. Results: Line-to-line cementing results in significantly higher pressurisation for longer periods of time leading to better interdigitation but a thinner mantle in some areas. Conclusions: The results of this study describe the in-vitro advantages and disadvantages of the line-to-line cementing technique. Background: The line-to-line cementing technique is proposed to create a press-fit in the femoral canal, which is contrary to modern cementing techniques. The term ‘French paradox’ has been used to describe the acceptable results associated with this technique. It has been suggested that the quality of the mantle may not be satisfactory, predisposing to early failure and aseptic loosening. Methods: The line-to-line cementing technique, where the femoral stem was oversized by 1 size compared to the broach, was compared to the standard cementing technique using corresponding sized broaches and stems, in 6 pairs of human cadaver femora with taper-slip design C-stems. Cement pressure was measured, and cement mantle thickness was analysed. A mixed effects model with random intercepts was used to examine the relationship between thickness of mantle and cementing technique and between pressure and cementing technique. Results: Line-to-line cementing results in significantly higher pressurisation for longer periods of time leading to better interdigitation but a thinner mantle in some areas. Conclusions: The results of this study describe the in-vitro advantages and disadvantages of the line-to-line cementing technique.

Post-polio syndrome is characterized by a late functional deterioration (usually after >=15 years from the initial infection) in patients with a history of paralytic poliomyelitis infection, and it is defined by the March of Dimes criteria. Patients with post-polio syndrome are at increased risk for falls and associated hip and femoral fractures as a result of lower bone mineral density, decreased lean muscle mass, and musculoskeletal deformities. Current evidence suggests that treatment modalities for femoral fractures should emphasize fixation that allows early progressive weight-bearing and ambulation to optimize functional outcomes. Good results after hip arthroplasty have been described with both cemented and uncemented implants in patients who have been treated for osteoarthritis, but there has been little evidence guiding hip fracture management. Anatomic challenges that are encountered are osteoporotic bone, a valgus neck-shaft angle, increased femoral anteversion, and a small femoral canal diameter. Intramedullary nailing of hip and femoral fractures can be challenging due to the small femoral canal diameter that frequently is encountered. Alternative methods of fixation have shown promising results. These include the use of sliding hip screws for hip fracture management and fixed-angle locking plates for hip and femoral fracture management.

Background Particularly in broach-only uncemented total hip arthroplasty, a narrow femoral canal presents a technical challenge. Traditionally such femurs have been considered to be Dorr A. To our knowledge, however, no study has reported on the relationship between isthmus width and the Dorr classification. Methods We reviewed 500 high-quality, hard copy radiographs. Dorr classification and isthmus canal width were measured using an electronic caliper by 5 independent observers with intraobserver and interobserver error calculated. For this study, we defined a narrow canal as being ≤10 mm at its narrowest point (isthmus). Results Eight percent (40) were Dorr A, 85% (424) Dorr B, and 7% (36) Dorr C. With respect to isthmus width for Dorr A, 63% (25) were ≤10 mm compared to just 13% (55) of Dorr B. However, overall because there were more Dorr B femurs, 69% of those with an isthmus of ≤10 mm were Dorr B. Conclusion In this population, almost 70% of patients with an isthmus ≤10 mm were Dorr B, with only 30% being Dorr A. When using a broach-only technique, isthmus width should be routinely measured on the preoperative anteroposterior radiographs so as to alert the surgeon to potential problems.

A case of two-stage minimally invasive surgical treatment of an elderly patient with bilateral inguinal hernia is presented: a recurrent oblique on the left, combined (femoral, obturator, oblique and direct inguinal) on the right with incarceration and necrosis of the small intestine in the femoral canal. Previously, the patient underwent closure of perforated ulcer of duodenum from upper-midline laparotomy, epicystostomy, transvesical adenomectomy from the lower-midline laparotomy. The first stage we performed diagnostic laparoscopy, minilaparotomy, reduction and resection of necrotic small intestine loop. The second stage was carried endovideoscopic total extraperitoneal allohernioplasty by the method of Extended-View Totally Extraperitoneal (e-TEP) on two sides. The positive results of the treatment indicate a high efficiency of video endoscopic alloplasty of occult hernias in a complex case. To diagnose and perform adequate surgical intervention with a combined femoral hernia, when the obturator and inguinal hernias are formed, but clinically do not manifest themselves, it is possible only with endoscopic examination of potential sites of hernia formation in the inguinal region, which is not possible with open plastic hernia of the inguinal region.Представлено наблюдение двухэтапного минимально инвазивного хирургического лечения пациента старческого возраста с двусторонней паховой грыжей: рецидивной косой слева, комбинированной (бедренной, запирательной, косой и прямой паховой) справа с ущемлением и некрозом тонкой кишки в бедренном канале. Ранее пациент перенес ушивание перфоративной язвы двенадцатиперстной кишки из верхне-срединной лапаротомии, эпицистостомию, транспузырную аденомэктомию из нижне-срединной лапаротомии. Первым этапом мы выполнили диагностическую лапароскопию, минилапаротомию, низведение и резекцию некротизированной петли тонкой кишки. Вторым этапом была произведена эндовидеоскопическая тотальная экстраперитонеальная аллогерниопластика по методике Extended-View Тotally Еxtraperitoneal (е-ТЕР) с двух сторон. Положительные результаты проведенного лечения свидетельствуют о высокой эффективности видеоэндоскопического варианта аллопластики оккультных грыж в сложном случае. Диагностировать и выполнить адекватное хирургическое вмешательство при комбинированной бедренной грыже, когда запирательная и паховые грыжи сформированы, но клинически себя не проявляют, возможно только при эндоскопическом осмотре потенциальных мест образования грыж в паховой области, что не представляется возможным при открытой пластике грыж паховой области.

Background Uncemented femoral components in primary THA are in widespread use, especially in patients younger than 50 years, but few studies have evaluated their survival into the late third and early fourth decade. Questions/purposes We evaluated (1) survivorship using femoral revision for any reason as the endpoint, (2) survivorship using femoral revision for aseptic loosening as the endpoint, (3) survival in patients younger than 50 years, (4) cumulative incidence of stem revision for periprosthetic femoral fracture and (5) the overall risk of revision (change of any part of the implanted components) at a minimum of 27 years of follow-up with an uncemented tapered titanium stem still in clinical use today. Methods We reviewed the clinical and radiographic results of 326 THAs performed in 326 patients (for 28 patients with bilateral THA, only the first hip was included in the analysis to ensure independent observations) using an uncemented grit-blasted, tapered collarless titanium alloy (TiAl6Nb7) stem between January 1985 and December 1989. In that same timeframe, we performed 1038 primary THAs. During that time, we used cementless stems in patients without severe femoral canal deformity and adequate bone stock for uncemented femoral fixation as determined by using the indication criteria described by the developer. In all, 34% (354 of 1038) were cementless; all cementless stems implanted during that time were the stem being studied here. No others were used. The mean (range) age at the time of surgery was 56 years (13-81 years). Sixty-seven patients were younger than 50 years at the time of primary THA. A competing risk survivorship analysis was used to estimate long-term survival. The minimum follow-up was 27 years (mean 28 years; range 27-32 years); at that time, 169 patients had died, and four patients were lost to follow-up. Results Survivorship at 28 years with revision of the femoral component for any reason as the endpoint was 87% (95% CI 83 to 90). Survivorship for femoral revision for aseptic loosening as the endpoint was 94% at 28 years (95% CI 90 to 96). Survival in patients younger than 50 years at the time of primary THA was 89% (95% CI 78 to 95) and 95% (95% CI 86 to 98) at 28 years for the endpoints of all stem revisions and aseptic stem loosening, respectively. The overall cumulative incidence of stem revision for periprosthetic femoral fracture was 4% (95% CI 2 to 7) at 28 years. The overall THA survival rate at 28 years with revision for any reason as the endpoint was 57% (95% CI 51 to 62). Conclusions Uncemented femoral fixation of a tapered collarless titanium alloy stem was reliable into the early fourth decade, especially in patients younger than 50 years. Late stem failures in the third and early fourth decade were mainly because of periprosthetic femoral fracture, while aseptic loosening occurred in undersized stems during the early second decade. Level of evidence Level IV, therapeutic study.

Background Total hip replacement (THR) after failed internal fixation of intertrochanteric femoral fractures is challenging. The aim of this study is to show the reliability of using standard cemented femoral stems in this operation. Methods This work included 107 THRs performed in 107 patients after failed treatment of intertrochanteric femoral fractures. The etiology of failure included 67 cases of failure of fixation, 16 cases of nonunion, 15 cases of avascular necrosis, and 9 cases of post-traumatic osteoarthritis. There were 48 males and 59 females. The mean age was 66 years (range 58-81). Failed dynamic hip screws were removed at the time of THR, and the screw holes were blocked with cement. All cases had cemented standard stem femoral prostheses. Results At an average 7.4 years with a minimum of 5 years of follow-up, 102 cases had good clinical and radiological outcomes and 5 cases had fair outcomes. One patient was infected and required 2 stages of revision arthroplasty. Two cases had intraoperative proximal femoral crack, and were treated by cerclage wires. Two patients had early postoperative dislocations. No patients had late periprosthetic femoral fractures or implant loosening. Conclusion Standard cemented femoral stems are reliable and cost-effective prostheses in such cases. It is not necessary to bypass the distal screw hole by doubling the femoral canal diameter as long as the bone holes are covered by cement.