Tissue preserving total hip arthroplasty using superior capsulotomy.

OBJECTIVE: The goals of a tissue-preserving minimally invasive approach to the hip are to allow early short-term recovery, achieve hip joint stability, minimize muscle strength loss from surgery, spare the peri-articular soft tissues, and allow unrestricted motion in the long term. INDICATIONS: Hip arthroplasty in patients with no pre-existing hardware, with a sufficient space between the acetabular rim and greater trochanter; management of subcapital femoral fractures in older patients. CONTRAINDICATIONS: Protrusio acetabuli. Joint stiffness. This is the main concern when undertaking the superior capsulotomy. Stiffness may result from bone causes, including ankylosis, large osteophytes, bone bridges etc., extra-articular retraction of surrounding soft tissues with capsular contracture of both ligaments and muscles, or a combination of bony and soft tissues causes, resulting in limited adduction. Indeed, maximal adduction is necessary to increase the distance between the apex of the greater trochanter and the superior acetabular edge. In the approach described in the present article, the real limitation is the impossibility to introduce a straight stem through the trochanteric fossa without weakening the trochantericarea. If adduction is restricted, excessive lateralization of the femoral stem would result in postoperative pain and discomfort, especially as we advocate immediate full weight bearing. Even though patients fare better when the trochanteric area is intact, many types of stem such as the GTS (Biomet), or stem Microplasty (Biomet) or even stem Parva (Adler Ortho) may pressurize the internal bone of the trochanteric structures. Therefore, these stems may be implanted in maximal hip adduction. This is the case in coxa profunda or coxa vara, which require more invasive and destabilizing surgical approaches. SURGICAL TECHNIQUE: Lateral position, 5-8 cm incision from the tip of the greater trochanter, identification and transaction of piriformis tendon. Anterior mobilization of the gluteus minimus and exposure of the trochanteric fossa. Removal of the superior portion (bone block) of the head and neck, and preparation of the femoral canal. Preparation of the acetabulum. Complete muscle relaxion is helpful to proceed to satisfactory trial reduction. POSTOPERATIVE MANAGEMENT: Patients may progress to motion and weight bearing without restriction. RESULTS: From April 2009 to December 2010, the first author operated on 463 patients, 275 for osteoarthrosis of the hip, and 188 for subcapital fractures of the femoral neck. Thereof, 375 (75 %) patients could walk with full weight within 6 h from the operation, and climb stairs 24 h later with low loss of blood, and rapid recovery.

[Suburban amebiasis: the diagnostic aspects via computed tomography and echography and the percutaneous treatment of amebic liver abscesses]. / Amebiasi sub-urbana: aspetti diagnostici con Tomografia Computerizzata ed ecografia e trattamento percutaneo degli ascessi amebici del fegato.

INTRODUCTION: Liver is the most common site of extraintestinal amebiasis and hepatic abscesses are the most frequent symptom, occurring in 3-9% of patients with amebic infection. Several studies have shown that drug treatment is more efficacious when combined with percutaneous drainage of the abscess, yielding quicker recovery and a positive body response. We report our US and CT findings in 16 patients with amebic abscesses, 12 of whom lived in a temperate peripheral area north-east of Naples. All patients had a clinical-diagnostic condition that we called "suburban amebiasis". Finally we report our personal experience with the US-guided therapeutic drainage of amebic abscesses with repeated cavity washings, which is important for positive parasitology. MATERIAL AND METHODS: We retrospectively reviewed the findings of 16 patients (11 men and 5 women; age range 36-78 years; mean 52) with amebic abscesses of liver examined with US and CT. US with a 3.5 MHz transducer was the technique of choice in all patients. 94% of liver abscesses and some extraintestinal complications were easily shown with this technique. CT angiography was then performed to detail and clarify US findings. Abscesses over 4 cm in diameter were submitted to US-guided percutaneous treatment which permitted abscess drainage, the collection of material for parasitology and repeated cavity washings. RESULTS: US showed multiple liver abscesses in 12 patients, which were multiseptate and formed by multiple hypo-/hyperechoic microabscesses in 4 of them. Four non-European patients had a single abscess, which is typical of tropical endemic forms. CT showed the amebic abscesses as hypodense roundish masses with clear-cut outline most often localized in the right lobe in the 12 multiple cases. After percutaneous drainage 13/16 patients (81%) reported less pain in the right hypochondrium and had a lower temperature; their hospitalization was also shorter. DISCUSSION AND CONCLUSIONS: Combined US and CT assessment facilitated the diagnosis of amebiasis and its differentiation from pyogenic abscess and hepatoma. The combination of US-guided drainage and drug treatment provides better results than either treatment alone and quicker improvement of patient conditions, with fewer extraintestinal complications. Percutaneous drainage should be used in abscesses bigger than 4-5 cm, those with questionable clinical-laboratory findings and finally those failing to respond to drug treatment alone. Positive parasitology of abscess content is related to repeated cavity washings after percutaneous drainage, likely because peripheral layers are much richer in amebae.