Elimination of the Femoral Neck in Measuring Femoral Version Allows for Less Variance in Interobserver Reliability

Background and Objectives: Producing consistent measures of femoral version amongst observers are necessary to allow for an assessment of version for possible corrective procedures. The purpose of this study was to compare two computed tomography (CT)-based techniques for the reliability of measuring femoral version amongst observers. Materials and Methods: Review was performed for 15 patients post-femoral nailing for comminuted (Winquist III and IV) femoral shaft fractures where CT scanograms were obtained. Two CT-based techniques were utilized to measure femoral version by five observers. Results: The mean femoral version, when utilizing a proximal line drawn down the center of the femoral head-neck through CT, was 9.50 ± 4.82°, while the method utilizing the head and shaft at lesser trochanter centers produced a mean version of 18.73 ± 2.69°. A significant difference was noted between these two (p ≤ 0.001). The method of measuring in the center of the femoral head and neck produced an intraclass correlation coefficient (ICC) of 0.960 with a 95% confidence interval lower bound of 0.909 and upper bound of 0.982. For the method assessing version via the center of the head and shaft at the lesser trochanter region, the ICC was 0.993 with a 95% confidence interval lower bound of 0.987 and an upper bound of 0.996. Conclusions: The method of measuring version proximally through a CT image of the femoral head–neck versus overlaying the femoral head with the femoral shaft at the most prominent aspect of the lesser trochanter produces differing version measurements by roughly 10° while yielding an almost perfect interobserver reliability in the new technique. Both techniques result in significantly high interobserver reliability.

Spontaneous Isolated Iliopsoas Tendon Tear in Elderly—Case Report and Review of Literature

Iliopsoas tendon tears are rare. These typically occur in young and can be associated with avulsion fractures of lesser trochanter. We report a case of full thickness rupture of iliopsoas tendon in 87-year-old male without avulsion of the lesser trochanter.

Incidental finding of hereditary multiple osteochondroma causing ischiofemoral impingement

Ischiofemoral impingement (IFI) has been described in the medical literature as a cause of hip pain. IFI occurs due to an abnormal contact or reduced space between the lesser trochanter and the lateral border of the ischium and is an often unrecognised cause of pain and snapping in the hip. Association of multiple exostoses and a skeletal dysplasia characterised by an abnormal modelling of bone metaphysis and osseous deformities is highly characteristic of this disease. Consequently, multiple exostoses may narrow the ischiofemoral space and cause impingement and pain, even in the absence of malignant transformation. Surgical excision of exostosis of the lesser trochanter is a safe and effective method of treatment for patients with IFI. We present a case of left hip pain with incidental finding of hereditary multiple osteochondroma causing IFI and discuss the predisposing factors and review of literature.

Minimally Invasive Technique for Treatment of Osteoid Osteoma: A Case of Anatomically Critical Lesion in an Adolescent Patient

Background: Osteoid osteoma is a benign osteogenic tumor affecting adolescents and young adults. It is managed using different treatment options. The lesions located around the lesser trochanter is rare and the management of these lesions is troublesome. Here, we report a case of an osteoid osteoma in the lesser trochanteric region, managed with a minimally invasive surgical excision of the lesion. Case Report: In a 14-year-old girl patient with nocturnal left thigh pain from 2 years before, conservative treatment with administration of non-steroidal anti-inflammatory drugs (NSAIDs) was not effective, and symptoms were refractory to medication. The day after surgery the patient was pain-free. Conclusion: The surgical management of osteoid osteoma in the region of the lesser trochanter is troublesome. The minimally invasive surgical excision of the lesion using CT-guided percutaneous drilling and resection of the osteoid osteoma is a safe, simple, cost-benefit, and effective technique.

Physiotherapeutic proceedings with patient after petrochanteric fracture

Introduction: The elderly are often affected by hip fractures. A trochanteric fracture is defined as when the fracture fissure is between the capsule and 3 cm below the lesser trochanter. The most common cause of these fractures is osteoporosis in the elderly. Treatment of a trochanteric fracture may be operative or conservative. The aim of this study was to define a plan of physiotherapeutic treatment in a patient after fixation of a trochanteric fracture with an intramedullary nail.Materials and methods: The work was written based on the medical history of a patient with a trochanteric fracture. The entire treatment procedure was carried out at the Department of Orthopedics, Traumatology and Oncology of the Musculoskeletal System, located at Unii Lubelskiej 1 in Szczecin.Results: Rehabilitation is an indispensable element in the treatment process of patients after a trochanteric fracture. It is implemented already from 1 day after the surgery in order to activate the patient as soon as possible. Such a procedure is to ensure faster activation of the patient and to avoid adverse changes resulting from too long immobilization.Conclusion: Rehabilitation is an indispensable element in the treatment of patients after a trochanteric fracture. Early patient activation reduces the risk of postoperative complications.

Multiple iliopsoas tendons: a cadaveric study and treatment implications for internal snapping hip syndrome

Purpose This cadaveric study aimed at describing the anatomical variations of the iliopsoas complex. Methods The iliopsoas complex was dissected unilaterally in 28 formalin-embalmed cadavers—13 males and 15 females with a mean age of 85.6 years. The number, courses and widths of the iliacus and psoas major tendons were determined. Patients with previous hip surgery were excluded. The following measurements were taken from the mid-inguinal point: the distance to the point of union of the psoas major and iliacus tendon; and the distance to the most distal insertion of iliopsoas. Results The presence of single, double and triple tendon insertions of iliopsoas were found in 12, 12 and 4 of the 28 specimens, respectively. When present, double and triple tendons inserted separately onto the lesser trochanter. The average length of the iliopsoas tendon from the mid-inguinal point to the most distal attachment at the lesser trochanter was 122.3 ± 13.0 mm. The iliacus muscle bulk merged with psoas major at an average distance of 24.9 ± 17.9 mm proximal to the mid-inguinal point. In all cases, the lateral-most fibres of iliacus yielded a non-tendinous, muscular insertion on to the anterior surface of the lesser trochanter and the femoral shaft, rather than joining onto the main iliopsoas tendon(s). The average total width of the psoas major tendon decreased with an increasing number of tendons: 14.6 ± 2.2 mm (single tendon), 8.2 ± 3.0 mm (2 tendons present) and 5.9 ± 1.1 mm (3 tendons present) (P < 0.001). Conclusions The results of this study suggest that multiple tendinous insertions of iliopsoas are present as an anatomical variant in more than 50% of the population. The non-tendinous muscular insertion of the iliopsoas on to the anterior surface of the lesser trochanter and femoral shaft found represents a novel anatomical variant not previously described. Level of evidence Level V

The Three-Dimensional Morphology of Femoral Medullary Cavity in the Developmental Dysplasia of the Hip

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.

A Novel Measurement Using Digital Radiography to Minimize Fluoroscopy in Total Hip Arthroplasty

Preoperative templating for total hip arthroplasty (THA) is fraught with uncertainty. Specifically, the conventional measurement of the lesser trochanter to the center (LTC) of the femoral head used in preoperative planning is easily measured on a template but not measurable intraoperatively. The purpose of this study was to examine the utility of a novel measurement that is reproducible both on templating and in surgery as a more accurate and practical guide. We retrospectively reviewed 201 patients with a history of osteoarthritis who underwent primary THA. For preoperative templating, the distance from the top of the lesser trochanter to the equator (LeTE) of the femoral head was measured on a calibrated digital radiograph with a neutral pelvis. This measurement was used intraoperatively to guide the choice of the trial neck and head. As with any templating technique, the goal was to construct a stable, impingement-free THA with equivalent leg lengths and hip offset. In evaluating this novel templating technique, the primary outcomes measured were the number of trial reductions and the amount of fluoroscopic time, exposures, and radiation required to obtain a balanced THA reconstruction. Using the LeTE measurement, the mean number of trial reductions was 1.21, the mean number of intraoperative fluoroscopy images taken was 2.63, the mean dose of radiation exposure from fluoroscopy was 0.02 mGy, and the mean fluoroscopy time per procedure was 0.6 seconds. In hips templated with the conventional LTC prior to the LeTE, the mean fluoroscopy time was 0.9 seconds. There was a statistically significant difference in fluoroscopy time (p < 0.001). The LeTE is a reproducible measurement that transfers reliably from digital templating to surgery. This novel preoperative templating metric reduces the fluoroscopy time and consequent radiation exposure to the surgical team and may minimize the number of trial reductions.