Painful total hip replacement due to sciatic nerve entrapment in scar tissue and lipoma

Painful total hip replacement remains a challenging problem because of the large amount of possible diagnoses. We report about a 64-year-old female patient who was misdiagnosed during 4years as psychiatric. She suffered of excruciating left retrotrochanteric pain after the implantation of a cementless total hip replacement and revision because of recurrent hip dislocations. Walking was limited to short distances using two crutches. The work-up at this time included the usual diagnoses and remained unsuccessful. No loosening, infection or malposition of the prosthesis could be found, and she had no neurologic deficits in her operated leg. An MRI was obtained to visualize the retrotrochanteric soft tissues and showed a tight scar surrounding the sciatic nerve, which was also compressed by an adjacent lipoma. Therefore, she was reoperated on to remove the lipoma and the scar tissue around the sciatic nerve. To decrease the risk of recurrent scarring around the sciatic nerve, an adhesion barrier was applied before closure. One year after the operation, the patient has no neurologic deficit, no more pain and is able to walk unlimited distances without crutches. Scar tissue around the sciatic nerve is frequently observed during revision surgery. However, we feel that sciatic nerve entrapment by scar tissue should be a part of the differential diagnosis of painful THR. MRI may be a useful tool to achieve this diagnosi

Brucellosis hip abscess without risk factor

Brucellosis has become a rare entity in many industrialised countries, because of animal vaccination programs. We report a first case in the literature of Brucella abscess in the hip region observed in Switzerland in a subject without any clear risk factor, leading us to conclude that abscess formation can be a rare manifestation of brucellosis. Because it can present in many different forms and locations without having characteristic clinics, a high index of suspicion is needed for the diagnosis even if the patient is a healthy athlete with no clear way of obvious route for contamination, and this even more if all the common causes of athletic hip pain have been ruled ou

Anatomic anterior cruciate ligament reconstruction: the two-incision technique

This article describes the anatomical two-incision reconstruction of anterior cruciate ligament (ACL) of knee. The major part of currently single incision tibial endoscopic techniques attempts to reproduce the most isometric anteromedial bundle of ACL. Often a relatively vertical femoral tunnel, respect to the notch, is drilled, which is not really efficacious in providing rotatory stability. The single incision technique was developed to obviate the necessity of the lateral femoral incision and dissection. This technical note describes a two-incision ACL reconstruction using an instrumentation, which avoids a large lateral femoral soft tissue dissection, and discusses the rational use of the two-incision ACL reconstruction techniqu

Gerdy tubercle osteotomy in surgical approach of posterolateral corner of the knee

Posterolateral corner (PLC) injuries of the knee are uncommon injury patterns that may result in significant degrees of functional disability. When surgery is necessary to address this injury a good knowledge of anatomy and a good surgical exposure is the mainstay. This report reviews the complex anatomy of the posterolateral corner (PLC) of knee and describes the osteotomy of Gerdy tubercle as a technical variant to approach this anatomical region. This surgical step allowing a good mobilisation of the multiple layers of ilio-tibial tract from distal to proximal makes an excellent exposure of the PLC structures with absence of morbidit

Medium-energy shock wave therapy in the treatment of rotator cuff calcifying tendinitis

To evaluate the results of the treatment with medium-energy extracorporeal shock wave therapy (ESWT) in rotator cuff calcifying tendinitis. Fifty-four non-consecutive patients, who were referred to our institute for rotator cuff calcifying tendinitis, were managed with a standardized protocol in four sessions of medium-energy (0.11mJ/mm2) ESWT administered with an electromagnetic lithotriptor. Pain was evaluated at the end of each session, functional state of shoulder was assessed at 1 and 6months after the end of procedure. All patients underwent radiographs and sonography imaging. No systemic or local complications. Thirty-eight patients (70%) reported satisfactory functional results. Radiographs and sonographs showed a disappearance of calcium deposit in 29 patients (54%) and in 19 patients (35%) it appeared to be reduced more than a half. A correlation was found between residual calcium deposit and the clinical outcome, but some patients showed a reduced pain without modification of calcium deposit. These results were unmodified at 6months follow-up. Our protocol of medium-energy ESWT provides good results overall about pain modulatio

Locking knee caused by subluxation of the posterior horn of the lateral meniscus

The authors report a case of repetitive locking knee caused by a subluxation of the posterior horn of a normal lateral meniscus. The posterior horn was sutured to the posterior knee capsule and the athlete resumed complete sports activity 4months after the surger

Femoral tunnel placement in anterior cruciate ligament reconstruction: rationale of the two incision technique

Endoscopic anterior cruciate ligament (ACL) reconstruction can be performed through one-incision or two-incision technique. The current one-incision endoscopic ACL single bundle reconstruction techniques attempt to perform an isometric repair placing the graft along the roof of the intercondylar notch, anterior and superior to the native ACL insertion. However the ACL isometry is a theoretical condition, and has not stood up to detailed testing and investigation. Moreover this type of reconstruction results in a vertically oriented non-anatomic graft, which is able to control anterior tibial translation but not the rotational component of the instability. Femoral tunnel obliquity has a great effect on rotational stability. To improve the obliquity of graft, an anatomical ACL reconstruction should be attempt. Anatomical insertion of ACL on the femur lies very low in the notch, spreading between 11 and 9–8 o'clock position and the center lies lower than at 11 o'clock position. Femoral aiming devices through the tibial tunnel aim at an isometric placement, and they do not aim at an anatomic position of the graft. Also, a placement of tunnel in a position of 11 o'clock is unable to restore rotational stability. The two-incision technique, with the possibility to position femoral tunnel independently by tibial tunnel, allows us to place femoral tunnel entrance in a position of 10 'clock that can most accurately reproduce the anatomic behaviour of the ACL and can potentially improve the response of the graft to rotatory loads. This positioning results in a more oblique graft placement, avoiding problem related to PCL impingement during knee flexion. Further studies are required to understand if this kind of reconstruction can ameliorate proprioception as well as clinical outcome at a long-term follow-up

Acute fractures of medial and lateral great toe sesamoids in an athlete

We report a case of acute fracture of both sesamoids of the great toe in an athlete. The fractures healed uneventfully after non-surgical treatmen

Multilobulated popliteal cyst after a failed total knee arthroplasty

Popliteal cyst is a rare finding after total knee arthroplasty (TKA), but when present, it might indicate a malfunction of the TKA related to generation of wear-particles, or loosening. We present a case of a multilobulated popliteal cyst developing in a patient 8years after primary TKA. The cyst was associated with a mechanical prosthetic loosening. The primary complaint of the patient was pain in the posterior region of the knee. A two-stage procedure consisting of cyst excision at first, followed after 5months by a revision TKA was performed. Intraoperatively, a darkish, multilobulated cyst with a well-defined thick wall filled with fluid containing polyethylene debris, communicating with the knee joint was found. After 3years of follow-up, the patient was satisfied and walked without the support of a cane. The patient presented a satisfactory knee range of motion. Clinical, radiological and ultrasound investigations ruled out popliteal cyst recurrence. A dissecting popliteal cyst associated with a failed TKA should be excised because it contains polyethylene debris that constitutes an induced factor for prosthetic loosening. A two-stage procedure with quite a long time in-between, as presented in this paper, can be a useful alternative to manage such a problem, in particular in very old patients associated with other medical problem