Unlock Your Hip Flexors

Unlock Your Hip Flexors

Unlock Your Hip Flexors is a program that gives the user a practical, easy-to-follow, natural method of releasing tight hip Flexors. Its aim is to help the user get the desired result within 60 days at 10-15 minutes per day. Naturally, the hip flexors are not meant to be tight. When they become tight, the user needs a way to make them loosen up. Unlock Your Hip Flexor has been programmed in such a way that it will help the user in doing just that. The plan was not created to be a quick fix. In fact, it will take the user close to 60 days to solve this problem and it is hard; yet the easiest as well the only that have been known to successfully help in the loosening of tightened hip flexors. The methods employed in this program are natural ones that have been proven by many specials. The system comes with bonus E-books Unlock Your Tight Hamstrings (The Key To A Healthy Back And Perfect Posture) and The 7-Day Anti-Inflammatory Diet (Automatically Heal Your Body With The Right Foods). There various exercises that can be done at home are recorded in a video format and are so easy that you will only get a difficult one after you have agreed to proceed to the next stage. Read more...

Unlock Your Hip Flexors Summary


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Contents: Ebooks, Training Program
Author: Mike Westerdal
Official Website: www.unlockmyhips.com
Price: $19.00

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Advances in Detection and Minimally Invasive Treatment

Cover illustration The hip joint distracted with an arthroscope within. The three insets are representative hip pathologies seen with arthroscopy loose body, labral tear, and synovial impingement (Courtesy of Dr. William Stillwell). 1. Hip joint Pathophysiology. 2. Hip joint Diseases. 3. Arthroscopy. 4. Hip joint Endoscopic surgery. I. McCarthy, Joseph C. DNLM 1. Hip Joint physiopathology. 2. Joint Diseases diagnosis. 3. Joint Diseases therapy. 4. Surgical Procedures, Minimally Invasive methods. WE 860 E12 2002 RD549 .E27 2002 617.5'81059 dc 21

Assessment of the Painful

Hip Adductor Tendonitis Mri

Rectus femoris m Obturator interna m .Pectineus m. and gemellus mm Iliopsoas m Iliopsoas m Adductor brevis m. Gracilis m. Inferior gemellus m.' Rectus femoris m. Obturator externus m. Quadratus femoris m. Iliopsoas m. Rectus femoris m. Obturator externus m. Quadratus femoris m. Iliopsoas m. Pectineus m. Quadratus femoris m. Fluid in the hip joint is best detected by ultrasonography. This is the preferred method in diagnosing arthritis of the joint. It is also valuable for diagnosing a child with a suspect transient synovitis. The amount of joint fluid can thus be determined and will be helpful in the decision whether to perform a joint aspiration for lowering intra-articular pressure. Ultrasonography is also indicated for an undisplaced hip fracture where a hemarthrosis might cause high pressure. Increased intracapsular pressure in the hip compromises the blood supply to the femoral head, with a risk for later segmental collapse.

Abdominal Aortic Aneurysms

Evidence of retroperitoneal hematoma may be seen as periumbilical ecchymosis (Cullen's sign) or flank ecchymosis (Grey-Turner's sign). Retroperitoneal blood may also dissect into the perineum or groin. Scrotal hematomas or inguinal masses may be seen on exam. Retroperitoneal blood may also irritate the psoas muscle and produce an iliopsoas sign. Blood may compress the femoral nerve and present as a neuropathy. The presence or rupture of an AAA does not typically alter femoral arterial pulsations.6

Advantages of the Lateral Approach

There are several technical advantages to lateral positioning for hip arthroscopy. The entire weightbearing articular surface of the acetabulum and femoral head can be visualized with a 30-degree scope via the paratrochanteric portals. The posterior and inferior aspects of the hip joint not only can be visualized, but also instrumented when the patient is positioned laterally. The orientation is quite familiar to the surgeon who performs total hip arthroplasty. The para-trochanteric portals puncture the superior hip capsule, which is slightly thinner, thereby facilitating cannula placement. Utilizing the primary portals with lateral positioning, the cannula passes through fewer muscle planes, and the potential injury to the lateral femoral cutaneous nerve is minimized. Pathology in the anterior superior quadrant of the hip is often encountered, and can be easily managed via the primary portals of the lateral approach. When the scope instruments are placed within the hip joint, their...

Orthopedic Procedures

Spinal scoliosis and hip subluxation, with subsequent hip dislocation, are common orthopedic concerns. Nonambulatory children diagnosed with spastic CP often exhibit an extensor tonal pattern of hip flexion, adduction, and internal rotation. Suggested contributing factors to subluxation of the hip include the strong pull of the adductor and flexor muscles of the hip joint in conjunction with weak hip abductor and extensor musculature.

Instrument Related Complications

The risk of instrument breakage is greater than with other joints and is not rare during arthroscopic hip procedures. The high conformity of the hip joint and the dense soft tissue envelope again limit the maneuverability of the instruments, resulting in significant torque on the relatively small devices, increasing the potential for breakage. In addition, the extra-length instruments used in hip arthroscopy create a longer lever arm and more potential for excessive torque or bending incidents. The variety of extra-length instruments available for arthroscopy is limited, and there is a tendency simply to use extra-length instruments available for other endoscopic needs, such as abdominal or gynecologic procedures. One must be very aware that these instruments are designed for more delicate soft tissue uses. Improper application in hip ar-throscopy makes them especially susceptible to breakage. Portions of such instruments may break off and drop free into the joint. It is imperative...

Techniques for Arthroscopic Removal of Loose Bodies

Once the patient is set up and the appropriate portals are established, systemic inspection of the entire joint should be carried out to avoid missing any loose body that may be present. Visualization of a loose body must not only be complete and unobstructed, but the arthroscope should also be positioned so that it does not interfere with the manipulation of the working instruments. The author prefers the lateral position, and working through anterior and posterior para-trochanteric portals. Selection of either a 30-degree or 70-degree arthroscope will provide visualization of the hip joint and, based on the location of the fragment, will allow manipulation and help avoid collision with the working instruments. Localization and survey of the loose bodies during the initial inspection will determine the best method for removal. Two techniques or methods can be employed to remove loose bodies these are based on the size and composition of the object. Small loose bodies or non-ossified...

Results Normal Labrum

Our observations of the normal labrum are consistent with earlier reports. The labrum appears as a fibrocartilaginous structure, triangular in cross-section, that surrounds the entire rim of the acetabulum. (Figure 12.3.) It is smoothly joined in-feriorly to the transverse acetabular ligament. Likewise, there is a smooth transition between the labrum and the articular cartilage within the acetabulum. A perilabral sulcus exists between the labrum and the capsule of the hip joint. This sul-cus is deepest superiorly and very shallow inferiorly, where the capsule lies against the transverse ligament. Synovial tissue lines this sulcus as well as the inner surface of the hip capsule.

Timing and Mechanism of Injury

Although mechanisms can be identified for individual fractures, the pattern of fractures throughout the lower leg can often provide evidence of the sequence of events. For example, a driver of a vehicle will often have direct-impact injuries from the dashboard striking the knees, producing compression fractures in the distal femur and shearing fractures as the thigh is projected backwards past the hip joint. Therefore, although

Traditional Surgical Approaches

Anterolateral Approach The Hip

Any discussion regarding minimally invasive approaches to the hip joint is predicated by the context in which it developed. The hip joint is the most deeply recessed joint in the body. Because of the many musculotendinous investing structures surrounding it, a number of open surgical approaches were developed. Each of these methods, importantly, passes through fascial planes between muscles supplied by major nerves. These planes are well detailed by Henry.1 Indications for hip surgery have historically been confined to regularly identified pathological entities. In the pediatric population these pathologies include joint sepsis, calcified loose bodies, treatment of joint instability, and tumors. In skeletally mature adults, joint arthrotomy has been utilized for osteonecrosis, osteotomy, cheilectomy, sepsis, removal of loose or foreign bodies, synovectomy, fracture management, and prosthetic replacement. This chapter will review the seminal features of the principal surgical...

Space Environment and the Organs Formation

Sampling from intact, well-defined meristem like root tips of Haplopappus gracilis (2n 4) derived from germinated seedlings shows fewer aberrations than those from de novo-generated root initials produced from aseptically generated propagules or stem cuttings. In the case of embryoids, the younger they are in their developmental progression, the more sensitive they are. The more advanced developmentally, the less damage.

Femoral Proximal Epiphysis Injuries

In injuries to the lateral side of the greater trochanter (Fig. 16, part 6), the victim may sustain bone bruises within the trochanter (Fig. 21) or more rarely in the femoral head and central fractures of the hip joint (or central dislocations when the femoral head is translocated into the interior of the pelvis) (7,26). In car occupants central fractures or injuries to the posterior margin of the acetabulum may result from forces travelling along Fig. 21. The mechanism of bone-bruise onset in the great trochanter and central fracture (dislocation) of the hip joint (X, impact direction). Fig. 21. The mechanism of bone-bruise onset in the great trochanter and central fracture (dislocation) of the hip joint (X, impact direction).

Neurovascular Anatomy

The arterial supply is from the medial femoral circumflex artery (a branch of the profunda femoris artery). The artery courses between the adductor longus and adductor brevis muscles to reach the middle third of the gracilis muscle. The diameter of the artery is between 1 and 2 mm and the diameter of the accompanying vena comitantes Figure 34 Typical configuration for a free gracilis muscle flap to correct facial palsy. The muscle is anchored along the zygoma and sutured into the modiolus. A cross-facial nerve graft was previously placed and anastomosed with the anterior branch of the obturator nerve. Figure 34 Typical configuration for a free gracilis muscle flap to correct facial palsy. The muscle is anchored along the zygoma and sutured into the modiolus. A cross-facial nerve graft was previously placed and anastomosed with the anterior branch of the obturator nerve. is between 1 and 1.5 mm. Multiple musculocutaneous perforators supply the overlying skin. No sensory component is...

Normal Inguinal Anatomy

The inguinal ligament and the iliopectineal ligament form two sides of a triangle, with the lacunar ligament at one vertex. The third side of the triangle is formed by the iliopsoas muscle. The external iliac artery (lateral) and vein (medial) lie on the anterior surface of the iliopsoas, and course through this fascial triangle (termed the femoral sheath), deep to the inguinal ligament. Once the vessels pass posterior to the inguinal ligament, they are renamed the common femoral artery and vein, respectively. Medial to the external iliac common femoral vein is the femoral canal. Femoral hernias occur through this space. Finally, the inferior epigastric vessels are the last branches of the external iliac vessels, prior to their passage under the inguinal ligament. Iliopsoas fascia (covering femoral nerve) Iliopsoas muscle The genitofemoral nerve is derived from roots L1-2, and runs on the anterior surface of the iliopsoas muscle, and divides into genital and femoral branches. The...

Traction Related Injuries

1491 cases, half of which were neuropraxias.2 In Sampson's recently reported series, 20 neuropraxias were noted in 530 cases.13 The nature of the hip joint requires greater traction on the limb than is used for other arthroscopic procedures, and effective traction is critical for success of the procedure. Byrd has reported using 25-50 pounds of traction,3 while Glick reports using 50-75 pounds.7 In Sampson's series of 530 patients, all cases of neuropraxias occurred from prolonged traction times of 5-6 hours on complex cases, and Sampson recommends using less than 50 pounds of traction, for less than 2 hours, as a general rule.13

Clinical Evaluation

RADIOLOGIC EVALUATION Roentgenographic evaluation of the pelvis and hips is a must in all unconscious patients who have sustained multiple injuries. The threshold for obtaining radiographs in demented elderly patients who have sustained minor falls should also be relatively low because those patients may be particularly difficult to evaluate.23 Lower extremity long bone fractures, as well as pelvic symptoms or signs, are also indications for these x-ray examinations. The x-ray evaluation should include a standard AP and a lateral view of the pelvis. If further studies are needed, AP views of either hemipelvis, internal and external oblique views of the hemipelvis as described by Judet and colleagues, or inlet and tilt views may be done. In certain instances, such views allow better identification and detail of the acetabulum and femoral head and neck. Always inspect not only the hip joint but also the femur and knee when evaluating hip disorders on x-ray films. Disorders to the knee...

Iatrogenic Intraoperative Complications

Manipulation of instruments within the hip joint can lead to either scuffing of the femoral head or breakage of the in-struments.6,9,13 While excessive traction has clearly been shown to increase the risk of neuropraxias, inadequate traction or poor arthroscopic technique can lead to inadvertant damage to articular cartilage. This can occur on either the femoral or the acetabular side. Third-body damage can also occur during hip arthroscopy from broken instruments. Use of plastic cannulae can contribute to this problem, and for that reason the author advocates using only metallic sheaths. Furthermore, given the depth of the hip joint and its surrounding soft tissues, the ar-throscopic instruments are subject to forces not commonly encountered in other joints. All instruments should be passed through metallic sheaths to minimize damage to the instruments and the hip.

Psoas Abscess and Hematoma

Iliopsoas Abscess Crohn Disease

Spontaneous dissection from a primary site in the retro-fascial space deep to the transversalis fascia into the ex-traperitoneal compartments is rare.3 The iliopsoas compartment is an extraperitoneal space covered by the iliopsoas fascia. The greater psoas muscle originates from the transverse processes of T12 and the lumbar vertebrae and extends inferiorly to merge with the iliac muscle at the L5-S2 level, becoming the iliopsoas muscle. The iliopsoas muscle passes beneath the inguinal ligament to insert on the lesser trochanter of the femur via the psoas (a) CT demonstrates a large fluid-filled abscess with small gas loculi and contrast material within the enhancing rim of the left psoas and iliopsoas muscles. (b) At a lower level, a fistula between the bowel involved by Crohn's disease and the iliopsoas muscle (arrow) is revealed. (a) CT demonstrates a large fluid-filled abscess with small gas loculi and contrast material within the enhancing rim of the left psoas and iliopsoas...

Anatomic Considerations

The psoas major originates from the transverse processes and bodies of the lumbar vertebrae and inserts on the lesser trochanter of the femur. 2. The iliacus originates primarily from the upper two-thirds of the iliac fossa and the ala of the sacrum and inserts with the tendon of the psoas major on the lesser trochanter of the femur. In its common insertion, it comprises the iliopsoas muscle group. In this way, the fascial investments of the iliopsoas, piriformis, and obturator internus muscles and the fascial sheaths of the superior gluteal arteries provide anatomic pathways to the buttocks, hips, and thighs. Superiorly, the pelvic tissues above the levator ani and coccygeus muscles are continuous with the extraperitoneal portion of the abdomen. The iliopsoas muscle group inserts medially on the lesser trochanter of the femur, and the piriformis and obturator internus insert laterally on the greater trochanter. (Reproduced from Meyers and Goodman.2)

TABLE 2652 Local Associated Injuries

AVULSION AND SINGLE BONE FRACTURES Anterior Superior Iliac Spine (Fig 265 14) This fracture typically occurs in adolescents because of forceful contraction of the sartorius muscle. Symptoms and signs are local pain, tenderness, and swelling and pain with flexion or abduction of the thigh. There is minimal displacement of the anterior superior iliac spine visible on the AP film of the pelvis. Anterior Inferior Iliac Spine This fracture occurs because of forceful contraction of the rectus femoris muscle. Symptoms and signs are sharp pain in the groin, difficulty with ambulation, and inability to flex the hip. The AP film shows downward displacement of the fragment, but this must be differentiated from the epiphyseal line of the os acetabuli.

Sigmoid Colon Radiologic Features

Lower Colon Black

The sigmoid mesocolon reflects obliquely off the level of the left sacroiliac joint to suspend the redundant sig-moid loops anteriorly. It forms an inverted V with its apex located at the division of the left common iliac artery. The left portion descends medial to the left psoas major muscle.107,108 The right segment descends into the

Pathways of Extrapelvic Spread of Disease

Perinephric Extramedullary Hematopoiesis

Surgical findings have not often localized the particular pathway of spread in the presence of a pelvic abscess with frequent necrotizing dissection toward the inguinal region, perineum, thigh and hip joint, buttock, and paravertebral gutter.8,14 I have established the correlation between the anatomic pathways and the radiologic documentation of the extrapelvic spread of disease.2 The insertions of the iliopsoas, piriformis, and obturator internus muscles, within their fascial investments, and the ensheathed penetrations of the superior gluteal arteries provide avenues of dissection to the buttocks, hips, and thighs. The course and relationships of the psoas major (1), iliacus (2), obturator internus (3), levator ani (4), and gluteal muscles (5) are shown. These are invested by fascia. The superior gluteal vessels (arrows) pass out of the pelvis at the level of the greater sciatic foramina. The course and relationships of the psoas major (1), iliacus (2), obturator internus (3),...

Minimally Invasive Surgical Approaches

The surgical approach in any operative procedure, arthroscopic or open, is the foundation for success and safety. Hip arthroscopy has evolved significantly over the last 15 years, and the accurate anatomic mapping and delineation of safe entry points or portals to the hip joint has been a major factor in this evolution. The depth of the hip joint from the skin, the intervening muscle and capsule, and the proximity of major neurovascular structures make the arthroscopic approach in the hip significantly more difficult than it is in other, more superficial and less confined joints. In choosing portals for hip arthroscopy one must be familiar with the landmarks, lo cal anatomy, and the relationship of these portals to vital structures which include the sciatic nerve and gluteal vessels posteriorly the lateral femoral cutaneous nerve anterolaterally and the femoral nerve and artery anteriorly. Refinements in positioning and hip joint distraction have improved our ability to utilize the...

Testing for Muscle Strength

An inability to walk on either the heels or the toes because of weakness in the foot dorsiflexors or plantar flexors, respectively, suggests an L5 radiculopathy in the former case and S1 root involvement in the latter instance. Similarly, difficulty in assuming or arising from a squatting position may indicate quadriceps weakness associated with L4 root compromise. Muscle atrophy can be detected by circumferential measurements of the calf and thigh bilaterally. Differences of less than 2 cm in measurements of the two limbs at the same level may be a normal variation.15 Weakness of the hip flexors suggests L3 compromise, of the quadriceps L4, the foot dorsiflexors and great toe extensors L5, and the calf S1 radiculopathy. Deep tendon reflexes are tested and compared one side with the other. An absent or reduced knee jerk suggests an L4 radiculopathy, biceps femoris jerk L5, and an asymmetric Achilles reflex an S1 root compression syndrome.19 Up-going toes in response to stroking the...

Supination NeutralPronation

Pinnate Muscle

Anatomically, this fiber arrangement has been classified as either parallel or pennate. A parallel arrangement means that the muscle fascicles are aligned parallel to the long axis or line of pull of the muscle. Muscles like the rectus abdominis, sartorius, and biceps brachii have predominantly a parallel architecture (Figure 3.7a). Pennate muscles have fibers aligned at a small angle (usually less than 15 ) to a tendon or aponeurosis running along the long axis of the muscle. An aponeurosis is a distinct connective tissue band within a muscle. This arrangement is called pennate because of the feathered appearance. The tibialis posterior and semimembranosus are primarily unipennate, while rectus femoris and gastrocnemius are bipennate (Figure 3.7b). An example of a multipennate muscle is the deltoid.

Portal Placement in the Supine Position Direct Anterior Portal

Dles and cannulas are then directed toward the femoral head along a trajectory 45 degrees from the horizontal and 30-45 degrees from the vertical midline.30,41,45 Anatomic studies have placed the portal an average of 6.3 cm distal to the anterior superior iliac spine.41 This portal directs the cannula sheath through the sartorius and rectus femoris muscle bellies, and enters the hip joint under the anterior margin of the acetabular labrum. This portal should be created after the arthroscope has been previously placed into the joint and direct visualization is possible. This portal can be established without the aid of the fluoroscope by placing the anterior stab wound in the same location as the initial point of entry for the spinal needle and moving down to the capsule bluntly with the switching stick. Visualizing the movement of the capsule anteriorly from the lateral portal has been sufficient to guide the placement of the switching stick, the sheath, and the elec-trocautery...

Arthroscopy Following Total Hip Replacement

A potential use of arthroscopy may be to reverse sympto-matically tight or impinging tendinous periarticular structures such as the iliopsoas. Although attractive, arthroscopy to lavage the joint of wear-related enzymes does not address the primary implant-related cause of potential osteolysis. It should be noted that neither of these applications has sufficient clinical data to warrant anything other than scrupulous judgment.

Treatment Interventions


May also react to pain by overactivation. Contracting the opposing or antagonistic muscle group may inhibit the overactive muscle and promote pain relief.16 For example, gluteal isometrics can inhibit an overactive iliopsoas muscle. Maintaining good mobility and contractility of the associated muscles of the pelvis and trunk is important. Examples are the pelvic floor exercises, abdominal bracing, lower trunk rotation (Figure 17.2.) and double knee-to-chest (Figure 17.3.). Gentle movement helps in preventing abnormal cross-links and shortening of the collagen tissue (Figure 17.4.). Overstretching in this phase may lead to delayed tissue healing. Having the patient perform submaximal isometric contractions of the trunk, hip, and knee muscles can help to prevent the muscle inhibition, while promoting improved nutrition to the tissues through increased circulation (Figure 17.5.). Standing while performing subtle weight-shifting onto the affected extremity can help to facilitate...

Siderophages Brain Demyelinating Injury

During the proliferation phase the myelin sheaths are destroyed (Fig. 10.7c, d) and removed by macrophages the dendrites are lost as well as MAP2-reac-tivity of spinal neurons (Fig. 10.7a, b). Signs of secondary (Wallerian) degeneration in distal ascending and descending long tracts appear above the lesion (rostral or cranial part of the cord to the injury), fiber loss occurs in the posterior columns. This will occur in the fasciculus gracilis and, to a variable degree, the fasciculus cuneatus, depending on whether the interruption is above, at, or below the cervical enlargement. Spinothalamic and spinocerebellar tract degeneration is more difficult to discern. Caudal to the lesion, the corticospinal tracts degenerate. At the level of the lesion, secondary degeneration of the neurons then begins, with central chromatolysis (axonal reaction) after spinal root transection (Fig. 3.1c).

Arthroscopic Anatomy and Assessment of the Normal Femoral Head

Arthroscopic Anatomy

The superior part of the head, leading down towards the fovea, is normally seen directly on entering the hip joint. Slight leverage of the arthroscope is required in order to view the posterior and anterior aspects of the femoral head. Liberal use of arthroscope rotation is made in order to gain as full an assessment of the head as possible.

Key References for Further Reading

J., Goebel, W., Maj, M. and Sartorius, N. Psychiatry as a Neuroscience. Sartorius, N. (Ed.) The usefulness and use of second generation antipsychotic medication review of evidence and recommendations by a task force of the World Psychiatric Association. Curr. Opin. Psychiat. 15 (Suppl. 1) (2002). Sartorius, N. (Ed.) The usefulness and use of second generation antipsychotic medication - an update. Curr. Opin. Psychiat. 16 (Suppl. 2) (2003).

Congenital dislocation and developmental dysplasia of hip

Previously this condition was known as congenital dislocation of the hip (CDH). However the correct term is developmental dysplasia of hip (DDH) because in many cases the condition is not present at birth but rather develops after birth. Secondly in a majority of cases there is no frank dislocation but a dysplasia (poorly developed acetabulum) leading to instability of the hip joint. This process covers a spectrum of conditions from acetab-ular dysplasia through to complete dislocation of the hip joint. Incidence has not declined (in the UK approximately 1.5 in 1000 live births) however, misdiagnoses have reduced with routine screening of infants using Barlow's and Ortolani's tests. CDH is thought to have a genetic predisposition, some geographical variation and joint laxity may be an aetiological factor. Girls are more commonly affected than boys and left side is more commonly affected than the right.

Reconstructive Surgery

In extensive defects, especially where tendons are exposed, myocutaneous vascularized flaps should be used. Medial thigh flaps, e.g., the gracilis myocutaneo-us pedicle flap, give the best results, because of their close proximity to the perineum, good mobility, and hidden donor site scars (Banks et al. 1986 Paty and Smith 1992 Kayikcioglu 2003). Other flaps using the inferior epigastric arteries can also be considered.

Extra Articular Conditions

The efficacy of arthroscopy in treating pathologic conditions in encapsulated environments (joints, bladder, etc) has spawned interest in further applications. Advancements in general surgery to endoscope soft tissue cavities have allowed treatment of inguinal hernias and gallbladder disease. Similarly, orthopedic arthroscopic procedures have begun to extend to extra-articular areas. As mentioned above, post-traumatic periarticular impinging ossification has been resected via the arthroscope. Glick has also reported his experience with this technique for iliopsoas and iliotibial band release.15 It should be emphasized that the results are preliminary the recovery can be protracted, especially for the il-iopsoas, and further study is necessary.

Orthopaedic Surgery

The most frequently performed operations in this category are hip and knee arthroplasty. Total hip replacement may be carried out under epidural, spinal or general anaesthesia. Peripheral nerve blockade may be useful for post operative analgesia (e.g. paravascular 3 in 1' and iliac crest block) but the hip joint is not easy to denervate in this manner due to its multiple nerve supply. Hip replacement may be carried out in the supine or lateral positions with the specific problems of these (see Chapter 4). Revision surgery and bone grafting to the acetabulum complicate the procedure greatly and add to the likelihood of extensive blood loss and the need for close haemodynamic monitoring. The most major incident to anticipate is cement reaction that generally occurs with cementing of the femoral, rather than actetabular prothesis. Various mechanisms have been suggested as implicated in cement reactions and these are listed in Figure SI.1. The clinical picture is one of hypotension...

Delayed Operative Procedures

For small full-thickness defects, rotational flaps from within the upper extremity provide adequate blood supply and coverage (Fig. 1). For some injuries, myocutaneous rotational flaps in the upper extremity are limited, as mobilization of one or more muscular components can significantly impair the patient's postoperative function. That is why fasciocutaneous flaps are preferred. There are a number of island pedicle flaps available for the hand. These are the reversed radial artery forearm flap, posterior interosseous flap, ulnar forearm flap, radial or ulnar perforator flaps, etc. The groin flap is another option but has the drawbacks of restricting the extremity, requiring a second surgery for division, and keeping the limb in a dependent position. In massive defects, a free flap must be considered. For the forearm, the latissimus dorsi is used as an island pedicle flap to the elbow. For areas distally, the latissimus must be taken as a free flap. Wounds over the elbow and humerus...

Anesthetic and Analgesic Medications

Fluid may extravasate under normal circumstances as well.8 It has been hypothesized that fluid may escape from the hip joint and enter the retroperitoneum, or cause distention via subcutaneous propagation, causing severe abdominal pain. Since it is theorized that this irrigation fluid is quickly resorbed, postoperative complaints of this pain are seldom encountered. Some practitioners therefore refrain from performing hip arthroscopy under regional anesthesia, where premature termination of the procedure may be required due to this complaint. Fluid overload due to extravasation of irrigant may cause serious electrolyte disturbances as well. This problem should be considered during any evaluation of intraoperative and postoperative complications for this procedure.

Structural Features of the Lower Extremity

The lower extremity, as defined by this volume, consists of the femur, tibia, fibula, and the bones of the ankle and foot (Fig. 1). These lower limb long bones are the strongest within the human body, building on our evolutionary heritage of bipedal locomotion. The lower extremity has evolved to accommodate large amounts of compres-sive stress, a condition that has been compounded by modern life, with its hard surfaces and the potential for concentrated forces from certain types of footwear (e.g., high heel shoes). The hip joint provides for a wide circular range of movement with limitation of movement largely defined by the interference of soft tissue. The thigh angles inward so that pressure on the femur must be redirected into the hip joint. This structure leaves the femoral neck relatively weak, although it is well supported by the large muscles of the buttocks and thigh.


Now that the technical challenges that previously limited hip joint access have been overcome, the indications for arthro-scopic surgery continue to expand. The ability to visualize the chondral articular surfaces directly has already greatly increased our understanding of early hip disease. Further im


Piriformis Gemelli

Proximal femoral development occurs as a result of the fusion of three separate centers of ossification the femoral head, the greater tuberosity, and the lesser tuberosity.1 Staheli has documented the changes of the proximal femur from the neonate to the adult.2 The neck shaft angle, which begins at 155 degrees in the neonate, decreases to 130 degrees, and the anteversion of the femoral neck, which begins at 40 degrees in the neonate, decreases to 10 degrees in the adult. These developmental changes can affect the biomechanics of the proximal femur, increasing vulnerability to injury from either trauma or repetitive stresses. Similar to the glenoid cavity of the shoulder, the acetabulum has a fibrocartilaginous labrum attached to its margins. Contrary to the shoulder, the acetab-ular labrum increases the depth of the joint rather than increasing its diameter. The labrum does not form a complete circle and is continued inferolaterally as the transverse ligament across the acetabular...


Shoots of cell culture-derived daylily (.Hemerocallis cv. Autumn Blaze) and haplopappus (Haplopappus gracilis) have been selected because they represent both major groups of the plant kingdom. The daylily represented herbaceous monocotyledonous plants and the haplopappus represented annual dicotyledonous plants. Haplopappus is valuable for studies of chromosome behavior because it has only four chromosomes in its diploid state (Figure 2-09). Daylily was chosen for the study because it has special lcaryotypic features (features related to the number, size, and configuration of chromosomes seen in the metaphase portion of mitosis) and it is a species for which a great deal of culture technology has been developed.

Labral Tears

Ment of the lenses and the microsurgical tools developed for treatment provide the least intrusive means of resecting or stabilizing a labral tear. It should be emphasized that the labrum is an important anatomic structure in the hip joint with many functions, especially in dysplasia. Overresection of labral tissue, more commonly seen with open arthrotomy, should be avoided. (See Chapter 12.)


Although some authors have described successful arthro-scopic evaluation of the hip joint without the use of distraction, we have found distraction essential to visualize the intra-articular structures and allow management with arthro-scopic techniques.1,5,6,8 There is, however, significant individual variation in the force required to achieve adequate distraction of the femoral head from the acetabulum. Eriksson et al.9 reported a force variation of 300-500 Newtons required in anesthetized patients to distract the hip adequately. Other authors have reported variance in the force necessary to distract the hip joint between approximately 100 Newtons (approximately 25 pounds) and 900 Newtons (250 pounds in non-anesthetized volunteer patients).6 For this reason, it is our practice to perform hip arthroscopy under general anesthesia and with adequate skeletal muscle relaxation, which reduces the force required to distract the hip joint. Although general, spinal, and epidural anesthetics...


Efficient phosphorus uptake has been found to be more closely related to the quantity of mycelium partitioned into the extraradical phase of the fungi (Abbott and Robson 1985 Morin et al. 1994). Jakobsen et al. (2001) reported that the phosphorus transport capacity of AM fungi is related not only to colonization rate, but also to the transport character of AM fungi themselves. The AM fungi cause few changes to root morphology, but the physiology of the host plant may change significantly. Tissue concentrations of growth-regulating compounds and other chemical constituents change, photosynthetis rates increase, and the partitioning of photosynthate to shoots and roots changes (Bethlenfalvay 1992). Allen et al. (1980) demonstrated differences in cytokinin content between Bouteloua gracilis plants with and without associated Glomus fasciculatus. They also reported quantitative and qualitative changes in GA-like substances in the leaves and roots of...


Hip arthroscopy in the supine position has proven effective for approaching and correcting various sources of hip joint pathology. This position provides ease of distraction for access to the space above the femoral head, good x-ray control of the initial steps for hip joint penetration, and satisfactory capacity to maneuver instruments for the correction of pathologic conditions encountered. Prepping and draping is accomplished per routine, including sterile drapes on the C-arm for fluoroscopic imaging. The applied drapes must allow free access to the involved hip for placement of any of the several portals needed (ie anterior, lateral, or posterior). Once the drapes are in place, the C-arm can be brought in just medial to the uninvolved limb and positioned above the involved hip for initial imaging. (Figure 8.10.) A spinal needle laid on the anterior aspect of the hip aids in identifying the ideal point of entry for both the insufflation needle and later for the arthroscopy...


Rowinsky, E., Kaufmann, S., Baker, S., Grochow, L., Chen, T., Peereboom, D., Bowling, M., Sartorius, S., Ettinger, D., Forastiere, A., and Donehower, R. 1996. Sequences of topotecan and cisplatin Phase I, pharmacologic, and in vitro studies to examine sequence. Journal of Clinical Oncology 14 3074-3084.

Room Setup

The lateral position cannot be utilized without the addition of specialized patient-positioning and hip traction devices. The patient must be secured so that the direct lateral position does not change with the application of traction. The positioning apparatus must not interfere with placement of the anterior portal and must not obstruct radiographic visualization of the hip joint. Many standard hip replacement positioners will meet these requirements. In addition, because the lateral position requires the use of the image intensifier across the table (to obtain an AP image of the lateral patient), one must allow for its placement either above or below the table. Although some prefer to tilt the C-arm over the distal aspect of the table, most have found it can be better accommodated out of the operative field by passing it under the table. This requires reversing the OR table so that the pedestal is under the

Clinical Features

The hallmark of severe hemophilia is hemorrhage into large joints (hemarthrosis). The ankles, knees, and elbows are most often affected, and when this occurs, patients may experience premonitory symptoms such as tingling followed by painful swelling of the joint leading to impaired movement. Recurrent hemathroses lead to inflammatory changes in the synovium and destructive changes in cartilage. This may result in total destruction of the joint, marked deformity, and disability. Muscle bleeding may also be an important cause of morbidity such as the classic iliopsoas muscle hematoma, which may cause painful flexion of the hip and compression of the femoral nerve. Bleeding may occur in any part of the body gastrointestinal, intracranial, and genitourinary bleeds are well-recognized features of hemophilia.


It is advantageous to have both 30- and 70-degree arthro-scopes available to allow complete visualization of the hip joint. There is no doubt that most of the intra-articular structures in the hip joint can be visualized with the standard 30-degree scope, by varying the angle of the arthroscope and by exchanging the scope among the various portals. There are times, however, when a 70-degree lens is needed for complete visualization, particularly when one is dealing with a tight hip joint. Surgical instruments and the arthroscope can be interchanged among any of the portals.

Loose Bodies

Removal of intra-articular loose bodies from synovial joints has essentially become the territory for the orthopedic surgeon with experience in arthroscopic techniques. Arthroscopy has been reported for and effectively applied to the removal of loose bodies and foreign objects in the wrist, elbow, shoulder, ankle, knee, and hip. Although widespread use of the arthroscope in the hip joint has not been as prevalent as its use in other joints, the indications are becoming more clearly defined. Treatment of symptomatic loose bodies within the hip joint or in the pericapsular region is the most widely reported and accepted application for hip arthroscopy. Advancement of specialized arthroscopic and distraction equipment has made this technique a first-line consideration for patients with documented symptomatic loose bodies within or surrounding the hip capsule. Although arthrotomy remains the gold standard technique for direct visualization and removal of intra- and extra-articular objects...

Dryopteris aemula

Dryopteris affinis 'Crispa Gracilis' with its dwarf proportions in the foreground in the Kennar garden. Dryopteris affinis 'Crispa Gracilis' with its dwarf proportions in the foreground in the Kennar garden. 'Crispa Gracilis' is a fastigiated forest-green 12-in. (30-cm) dwarf suggestive of a miniature conifer. It is a favorite for foreground plantings.

Superficial nerves

The genitofemoral nerve arises from the first and second lumbar nerves and completes the innervation of the abdominal wall and groin areas. At first it passes obliquely forwards and downwards through the substance of the psoas major. It emerges from the muscle and crosses its anterior surface deep to the peritoneum, going behind, posterior to, the ureter. It divides a variable distance from the deep inguinal ring into a genital and a femoral branch. The genital branch, a mixed motor and sensory nerve, crosses the femoral vessels and enters the inguinal canal at or just medial to the deep ring. The nerve penetrates the fascia transversalis of the posterior wall of the inguinal ligament either through the deep ring or separately medially to the deep ring. The nerve traverses the inguinal canal lying between the spermatic cord above and the upturned edge of the inguinal ligament inferiorly the nerve is vulnerable to surgical trauma as it progresses along the floor of the canal (the...


Dismemberment does not require anatomical knowledge, although such knowledge makes the segmentation of the body much easier. Knowledge of anatomical relationships between bones becomes apparent in the patterns of disarticulation and careful documentation of such cuts must be completed. An incorrect conception of the body segments, especially at the shoulder and hip joints, often leads to dismemberment attempts through the upper one-third of the humerus and femur rather than through the joint itself. Presumably this is triggered by the perpetrator seeing a slimming of the body segment above or below the joint itself and incorrectly assuming that this is the easiest portion to cut. False starts are common and can provide information on the sequence of tool types used during the dismemberment.


Although hip arthroscopy is technically demanding, it is increasingly being practiced. As surgeons successfully master the ability to navigate the hip joint arthroscopically, conditions will be diagnosed at an earlier stage, and attempts at arthroscopic management will be made. This chapter has highlighted how numerous conditions affect the femoral head, but also how many are not diagnosed until arthroscopy. Since many of these conditions are found in young people, minimally invasive, joint-preserving techniques are essential for treatment. Although at present operative interventions are limited and results are extremely variable, as surgical skills and instrumentation improve, combined with earlier referral of suitable patients, results will also undoubtedly improve. Controlled studies, if practical, are desirable to counter the occasional criticism (usually by those without experience of the technique) that hip arthroscopy is a procedure looking for an indication. Nothing could be...

Treatment Algorithms

Patients thought to have chronic anterior hip pain can generally be divided into those who are tender and those who have mechanical symptoms. Rarely, disc or nerve root pathology in the upper lumbar levels can refer causalgic pain via the L2-L3 dermatomes.1 Many patients with anterior groin or thigh pain are weekend warriors who present with a chronic strain of the rectus femoris or the iliopsoas musculature. Usually, such patients have made the diagnosis but seek medical attention because they are not getting well as quickly as they think they should. These patients generally require reassurance, and should be instructed in stretching and strengthening exercises. Rarely, some patients who think they have a pulled muscle will have an avulsion fracture noted on plain films at the rectus femoris origin, ie the anterior inferior iliac spine or at the insertion of the iliopsoas on the lesser trochanter. These patients do well with conservative therapy. adduction of the lower extremity....


Weight-bearing exercises are recommended, i.e. stair climbing, brisk walking, stepping. Falls in this group are more likely to result in a fracture, therefore, exercises that encourage strength, balance and coordination should be encouraged. Strengthening should target individual vulnerable sites and postural muscles, such as hip flexors and extensors and back extensors. Exercise leaders should include exercises that will help to develop motor skills and coordination. Care should be taken to avoid making the exercises complicated until motor skills have improved.

Plane Accidents

With commercial aircraft, the heavier plane and greater speeds lead to much greater fragmentation on impact (30,68). The detachment of body segments is extreme and, in some cases, the largest portions found are only a few inches in length. The lower extremity is often divided into small parts with only sections recovered. A frequent recovery pattern is to find jointed bone fragments, longer bone segments having been shattered. In the lower extremity, isolated feet, knee, and hip joints are a common find. Identification as to side is relatively straightforward, but assessment of sex, age, and possibly stature can be tedious, time consuming, and fraught with error. Most final identifications of body segments are now done through DNA analysis.

Postnatal Growth

Associated with the force that is demanded of a muscle. Muscles used for locomotion, such as the hindlimb biceps femoris, have larger-diameter muscle fibers and more connective tissue than postural muscles, e.g., the psoas major. The following discussion will highlight the cellular aspects of postnatal bone, skeletal muscle, and adipose tissue accretion. These tissues compose the majority of body mass in all domestic animal species.


Arthroscopic access to the hip joint requires specialized instrumentation that allows controlled, atraumatic penetration of the periarticular soft tissues, abductor musculature, and hip joint capsule. Because of the depth of the hip joint from the surface, specially designed extra-long arthroscopic instruments are generally required to enter the hip joint and perform any necessary procedures. In selected smaller individuals who have thin soft tissue envelopes, it is sometimes possible to use arthroscopy instruments designed for use in the shoulder or knee. It is best, however, not to expect this to be the case. All arthroscopic instrumentation should be passed through sturdy metallic sheaths or cannulae long enough to traverse soft tissues surrounding the hip once a portal is made. Retained cannulae prevent loss of joint capsular distention and loss of visualization through multiple perforations in the hip capsule. They also reduce the risk of instrument breakage, further trauma to...


The torn acetabular labrum has been identified as a cause for hip discomfort in young athletes. (Figure 15.1.) Clinical features include a painful click in the inguinal area that radiates toward the gluteus, and symptoms of catching or giving way at the hip joint. In general, athletes will remember an antecedent traumatic event that often involves sports, such as karate, which require forceful hip flexion and abduction, and forceful knee extension. On physical examination, the painful click can be reproduced by a Thomas flexion-to-extension maneuver.


Despite the availability of numerous microvascular tissue flaps, only a few are routinely used in the head and neck including the radial forearm, fibula, rectus, scapula, latissimus, jejunum, iliac crest, and gracilis. The radial forearm or so-called 'Chinese' flap was first described by Yang et al. in 1981 (43). It provides thin pliable fasciocu-taneous tissue from the ventral wrist and forearm based on the radial artery, cephalic vein, and medial and lateral antebrachial cutaneous nerves. The proximal fibrofatty tissue in the forearm can also be harvested for augmentation or coverage in selected cases. The radial forearm flap can also be harvested with a portion of the underlying Harii et al. introduced the gracilis free flap in 1976 for the surgical treatment of facial paralysis (50). It provides a tubular muscle innervated by multiple neural fascicles from the anterior division of the obturator nerve. The blood supply is from the medial femoral circumflex artery (a branch of the...


Often in microvascular surgery it is necessary to perform neural anastomoses to reconstitute motor or sensory function to the transferred flap tissue. Essentially, a nerve trunk is a collection of axons (nerve fibers) ensheathed in endoneurium, peri-neurium, and epineurium. Endoneurium surrounds the individual axons, perineur-ium encases groups of axons, and epineurium surrounds the perineurium and ensheaths the entire nerve trunk (Fig. 25). A nerve fascicle is a group of axons and its perineurium and it is the smallest component of a nerve trunk that can be used for microneural anastomosis. A monofascicular nerve (e.g., facial nerve trunk) consists of a single large fascicle ensheathed by epifascicular epineurium. A polyfas-cicular nerve (e.g., inferior alveolar nerve and lingual nerve) consists of many small fascicles of varying size with intervening interfascicular perineurium all ensheathed by epifascicular epineurium. In cases of microvascular transplantation of muscle for facial...

Surgical Highlights

The gracilis muscle is easily harvested with the patient in a supine position and the lower limb in a flexed and abducted position exposing the inner thigh. A linear incision is made over the muscle along a line tangent to the pubis and medial condyle of the tibia. The intermuscular septum between the gracilis muscle and adductor longus muscle is identified, and the skin and subcutaneous tissues are dissected off the gra-cilis. The vascular pedicle (medial femoral circumflex artery and vein) is noted entering the anterior aspect of the gracilis muscle posterior to the adductor longus muscle. The anterior branch of the obturator nerve is also noted along the posterior border of the adductor longus muscle splitting to innervate several longitudinal muscular fascicles separately upon entering the gracilis muscle. If only a single functional unit is needed, only the anterior longitudinal half of the muscle is harvested since the vascular pedicle enters this portion. The neurovascular...

Muscle Length

Muscle imbalance is often present both pre- and postopera-tively due to pain or prolonged poor posture. Certain patterns of muscle imbalance are commonly found at the lumbo-pelvic-hip complex. Janda described certain muscles as being prone to either tightness or lengthening. This tightness may be associated with or without weakness. Lengthening is associated with stretch weakness.16 Muscles prone to tightness are the iliopsoas, rectus femoris, hamstrings, quadratus lumborum, hip adductors, low back extensors, hip external rotators, and the gastroc-soleus. Muscles prone to lengthening and weakness are the opposing or antagonistic muscle groups such as the abdominals, hip extensors, and abductors. On preoperative examinations, McCarthy also found that hip flexors are often shortened in patients with labral tears.1 Pain can lead also to adaptive shortening of the hip flexor muscle and inhibition of the hip extensors and abductors.


Stretching the hip flexors in prone lying (Figure 17.6.) may be initiated, as well as more combination movements that gently stretch the piriformis and hip external rotators (Figure 17.7.). As mentioned earlier, other shortened muscles include the hamstrings, rectus femoris, gastroc and soleus, hip adductors, and the quadratus lumborum. Most research on stretching has been conducted on healthy muscle tissues. The optimal duration of static stretching has been variable, but many studies recommend a 30-second stretch. Injured muscles may need a longer stretch stimulus.27 Different patients may require different amounts of stretch duration. Patients should be advised to stretch to the point of tension and maintain that position until relaxation occurs. The stretch can then be progressed. Soft tissue mobilization to restore muscle extensibility and play are also indicated at this phase. Proprio-ceptive neuromuscular facilitation (PNF) such as hold-relax and contract-relax are also...


Hereditary spastic paraplegia (HSP) is characterized by the retrograde degeneration of the longest axons of the central nervous system those of the crossed cortico-spinal tracts and of the fasciculus gracilis. In about half of the autoptic cases examined, the spinocerebellar tracts were also involved. Axons of the corticospinal tracts arise from pyramidal neurons in layer V of the motor cortex and project through the internal capsule to reach the ventral surface of the medulla where they form two elongated swellings, the pyramids. These axons cross the midline at the junction between the bulb and the spinal cord and descend in the contralateral funiculus of the spinal cord. The crossed corticospinal tract conveys voluntary motor impulses to the secondary motor neurons located in the ventral horns of the spinal cord. The fasciculus gracilis is composed of the central branches of axons of pseudounipolar neurons located in dorsal root ganglia and ascend in the most medial part of the...

The Dynamic Foot

Pathologic change that is seen with different biomechanical foot types is well known, and although there can be deviations from the norm, for the most part assumptions can be made with a good degree of accuracy. The patient with a planus foot often presents in clinical practice with a complaint of arch pain, heel pain, hallux abducto-valgus with bunion deformity, and hammer toe deformity. Other complaints may involve joints above the ankle level including the knee and hip joints. The patient with a cavus foot often presents with complaints of chronic lateral ankle instability, digital contracture, and metatarsophalangeal joint contracture, with increased declination of the metatarsal heads. Significant metatarsalgia with intractable plantar keratosis (deep, nucleated callus) formation may be a complaint in addition to medical concerns above the ankle. This biomechanical classification system with its inherent abnormalities in fact may lead to a better understanding of foot pathologies...

Complex Injuries

Complex injuries imply multifocal or multistructural defects. The latter can involve the simultaneous injury of soft tissue, nasal destruction with cartilaginous injury, mucosal defects, joint (e.g., temporomandibular) or bone injury (e.g., maxilla, mandible, and skull), or muscular destruction (e.g., facial muscles and tongue). Complex defects occasionally require more than a single free flap due to the size or a compound, multicomponent flap for a successful reconstruction.17 This might be the combination of a local flap with a free flap, the usage of different tissue components within a single flap (e.g., bone), or the combination of several free flaps on a single or more than one pedicles. Some examples have been given above such as the radial forearm flap containing tendon, muscle or bone or the circumflex iliac free flap containing iliac crest, or sartorius muscle. The largest tissue reservoir is provided by the subscapu-lar vascular axis. The scapular, parascapular, latissimus...


Approximately 18 bursae surround the hip joint. These are derived developmentally from and are physiologically similar to synovium and tendon sheaths. As a result, they suffer from the same inflammatory afflictions which cause problems to the joint itself. Conditions that affect the bursae include traumatic inflammation, which is usually secondary to overuse or excessive pressure infections metabolic disorders such as gout and benign and malignant growths.

Lower Extremity

The thigh has three compartments the anterior, medial, and posterior. The anterior compartment contains the vastus lateralis, the vastus intermedius, and the vastus medialis muscles, as well as the sartorius and rectus femoris muscles. The femoral artery and nerve also traverse the anterior thigh compartment. The medial compartment contains the adductor longus, the adductor brevis, and the adductor magnus muscles, plus the gracilis muscle. The posterior compartment contains the semimembranosus, the semitendinosus, and the biceps femoris muscles. The sciatic nerve also traverses the posterior compartment.

Mitotic Chromosomes

The first report in plants dates back to 1984, when De Laat and Blaas (1984) described chromosome analysis and sorting in Haplopappus gracilis (Asteraceae). Since that time, chromosome analysis (flow karyotyping) has been reported in 18 plant species (see Chapter 16). Although the early experiments involved the preparation of samples (suspensions of intact chromosomes) from protoplasts, current methodology is based on mechanical homogenization of synchronized meristem root tips (DoleZel et al. 1992). Flow karyotyping involves staining chromosomes in suspension with a DNA fluorochrome (typically PI or DAPI). The resulting distribution of fluorescence intensities is called flow karyotype. Due to the similarity in size, only a few chromosomes within a karyotype can usually be discriminated as single peaks on a flow karyotype. This limits the application of flow karyotyping for analysis of structural and numerical chromosome changes. Despite this, a number of reports confirms the utility...

Taxonomic index

Caenorhabditis elegans 123 Candida albicans 254 Candida utilis 254 Caudina arenicola 93 Chaetoceros calcitrans 151 Chaetoceros gracilis 144 Ciona intestinalis 123 Clypeaster japonicus 260 Concentricycloidea 8 Cricosphaera carterae 144 Cricosphaera elongata 144 Crinoidea 8,208,210,252 Cucumaria 150 Cucumaria echinata 4,259 Cucumaria frondosa 2,94,155,233-238 Cucumaria japonica 257


Traumatic events about the hip joint are a frequent occurrence. While most fractures of the femoral neck or acetabu-lum are successfully treated by reconstituting the bony architecture, articular injuries can and do occur. Epstein reported that the high incidence of chondral damage present following a fracture dislocation of the hip warranted an arthro-tomy in every case.14 The high risks associated with open surgery in the early post-trauma period (infection, contracture, deep vein thrombosis, pulmonary emobolus, heterotopic bone, and neuromuscular dysfunction) have limited enthusiasm for that approach. The minimally invasive nature of arthroscopy, however, significantly reduces these risks. The senior author


Each of the previously noted approaches is intended to achieve joint arthrotomy. Most of the procedures for which they are performed involve femoral head dislocation. (Figure 9.10.) For those surgeries not involving prosthetic replacement there is an attendant risk of developing osteonecrosis. Arthrotomy of the joint requires an inpatient hospital stay and a potentially extended rehabilitation course. For major joint reconstruction or bone grafting these postoperative sequelae are readily justified. For the patient with a symptomatic loose body or labral tear, however, these open techniques are less advantageous. It is for this reason that, however difficult, minimally invasive approaches to the hip joint have been developed.

Skeletal Musculature

The skeletal muscles are a relatively rare bleeding site in coagulation disorders such as septic DIC. However, iliopsoas muscle bleeding may be seen in septic individuals with severe deterioration of coagulation factors.113 Relevant differential diagnoses of iliopsoas muscle bleeding (potentially leading to fatal exsanguination) include hemorrhage due to trauma, anticoagulant medication, and hypothermia.114

Surgical Indications

Despite the anatomic constraints of the hip joint, minimally invasive techniques to access this joint continue to evolve. As noted earlier, these efforts have paralleled an increased understanding of hip anatomy, improvements in joint distraction techniques whether the patient is in the lateral or supine position, as well as instrumentation developed specifically for the hip. In addition, developing clinical and radiographic expertise in diagnosing intra-articular lesions has resulted in an increasing necessity for accessing the joint. Until recently, radiographic demonstration of loose bodies within the hip joint required an open arthrotomy for treatment. The open procedure, however, carried with it a plethora of potential risks. These risks included avascular necrosis of the femoral head (especially if the hip was dislocated or a posterior approach was utilized), neurovascular injury (especially if a lengthy split was made in the gluteus medius during a direct lateral approach), and...

Anal incontinence

The final surgical options are reconstruction of the sphincter or permanent faecal diversion. An electronically stimulated gracilis muscle flap can be used to create a neosphincter around the anal canal and some centres implant artificial neosphincters. Both of these operations have been associated with implant-related infection and impaired evacuation.


Once the patient can move smoothly through the range of motion it is time to further strengthen the affected muscles. Restoring strength to the hip-stabilizing muscles should begin in their shortened range. The gluteus medius functions primarily eccentrically in the initial contact to the midstance phase of gait to stabilize the pelvis on the femur in the frontal plane. Before developing eccentric strength, the gluteus medius must achieve isometric and concentric strength. Isometric contractions can be elicited in the hips during a lateral-push wall exercise. (Figure 17.9.) Isometric exercise duration should begin at 5-10 seconds. Isotonic strength can be attained through a side-lying leg lift. This exercise is often done incorrectly with the patient rotating the hip externally to substitute for the weak gluteus medius with the tensor fascia lata and hip flexor muscles. (Figure 17.10.) Leg lifts can also be performed into hip extension and hip adduction. Active hip extension in the...

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