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. Continue reading...

Unlock Your Hip Flexors Summary

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Technique for Percutaneous Biopsy of the Synovium of the Hip Joint

FIGURE 1 Simulation of needle approach to the hip joint on a transverse image. Computed tomography R right H horizontal line A point where the needle tip first reaches the bone A-B simulation of needle approach. FIGURE 1 Simulation of needle approach to the hip joint on a transverse image. Computed tomography R right H horizontal line A point where the needle tip first reaches the bone A-B simulation of needle approach. PBS is performed under local anesthesia on an outpatient basis. However, because the patient received sedative drugs before the procedure, the patient has to be escorted back home. PBS is achieved under single plane fluoroscopy guidance. An SNCN allows for multiple sampling in the inferior and medial joint recess, which is a frequent site of synovial proliferation and the preferred site for tissue sampling (Fig. 1). The patient is placed supine on the X-ray table with the leg stabilized in internal rotation by sandbags. The hip joint is approached through an...

Diagnostic Round And Anatomy Of The Peripheral Hip Joint Cavity

Patient Positioning And Draping

Similar to the knee joint, the key to an accurate and complete diagnosis of lesions within the hip joint is a systematic approach to viewing. A methodical sequence of examination should be developed, progressing from one part of the joint cavity to another and systematically carrying out this sequence in every hip. FIGURE 11.6. Introduction of the arthroscope to the hip joint periphery guidewire (a), dilating trochars (b), starting position of the arthroscope (c). (Reprinted with permission from Dienst et al.44) FIGURE 11.6. Introduction of the arthroscope to the hip joint periphery guidewire (a), dilating trochars (b), starting position of the arthroscope (c). (Reprinted with permission from Dienst et al.44) Moving the scope medially over the medial synovial fold, the medial neck area can be examined. By rotating the 25-degree lens, the medial margin of the femoral head, the medial wall of the capsule with the zona orbicularis and the medial recess can be inspected. Rotating the lens...

Arthroscopic Compartments Of The Hip Joint

Placement of portals and maneuverability of the arthroscope and instruments within the hip joint are more difficult than in other joints. This difficulty is related to various anatomic features a thick soft tissue mantle, close proximity of two major neurovas-cular bundles, a strong articular capsule, a relatively small intraarticular volume, permanent contact of the articular surfaces, and the sealing of the deep, central part of the joint by the acetabular labrum. Thus, if no traction is applied to the hip, only a small film of synovial fluid separates the articular surface of the femoral head from the lunate cartilage and acetabular labrum (artificial space). The anatomy of the acetabular labrum must be considered when accessing the hip joint. The labrum seals the joint space between the lunate cartilage and the femoral head. Even under complete muscle relaxation during anesthesia, the labrum maintains a vacuum force of about 120 to 200 N, which keeps the femoral head within the...

Gracilis muscle dissection and muscle insertion

Gracilis Myocutaneous Flap

The gracilis muscle or myocutaneous FFMT is the best choice of donor muscle for elbow or hand reconstruction in BPI reconstruction. The requirement for a myocutaneous flap is more common than muscle alone to allow monitoring of the flap's viability. The gracilis muscle is a long strap muscle with a long distal tendon, vascular-ized by a long dominant neurovascular pedicle. A single motor nerve, the anterior branch of the obturator nerve, can be dissected and traced upward to the obturator foramen or retroperitonium to obtain a very long length, 10 cm or more, which is very important for direct nerve coaptation after Fig. 7. A 21-year-old patient in a motorcycle accident sustained total root avulsions C4-T1 of his right brachial plexus 10 months before the reconstruction. A left gracilis myocutaneous FFMT for finger extension using the XI nerve as a neurotizer, and a right gracilis myocutaneous FFMT for finger flexion using IC nerves as a neurotizer were performed in two different...

Iliopsoas Tendon

The iliopsoas tendon lies superficial to and along the medial margin of the anterior capsule of the hip. The tendon inserts into the lesser trochanter (24). A bursa that frequently communicates with the hip is frequently seen in this location and may be distended as the result of underlying joint pathology, or as a primary iliopsoas bursitis (25). Alternatively, one can have an iliopsoas tendinosis in the absence of a preexisting bursitis, in which a peritendinous injection is requested (Fig. 2). A lateral approach to the tendon often requires use of a lower frequency transducer and curved linear or sector geometry. The neurovascular bundle lies medial to the tendon, so that it is advantageous to approach from the lateral margin of the tendon and perform a small test injection to confirm needle position. A successful injection will show the appearance of fluid and or microbubbles distributed along the long axis of the tendon (Fig. 2).

General issues and definitions

For thousands of years humans have tried to understand their world. Language allowed them to name all the objects pertaining to their lives, including ailments and diseases. In antiquity the question had already arisen whether things are real because humans give them a name or whether nature exists independently outside human existence. Questions of this kind can be reactivated regarding modern discussions in psychiatry concerning diagnosis. Norman Sartorius reflected that diagnosis and classification are a means of viewing the world.(1) Indeed, it is hard to imagine how it would be possible to exist without some kind of classificatory order. Classification, then, is a systematic arrangement of the world in order to master the otherwise chaotic entities and structures, and corresponds to the structure of human thinking.

The development of ICD10

The psychiatric section of the 10th Revision of the International Classification of Diseases was worked through in several conferences under the chairmanship of Norman Sartorius. After a meeting of WHO representatives and consultants, together with representatives of the American Drug and Mental Health Administration in Copenhagen in 1982, several further meetings took place (e.g. in Djakarta and in Geneva in 1984) in which a provisional psychiatric classification was designed. The first draft of the psychiatric chapter (Chapter V (F)) was written in English and distributed by the World Psychiatric Association to the national psychiatric societies for comment and criticism. Nine years later the Clinical Descriptions and Diagnostic Guidelines(37> were published. Following the work on the English text, the Guidelines were translated into many other languages including Arabic, Chinese, French, German, and Spanish by 1995 they were available in 19 languages. Many of the translations and...

Musculoskeletal Morphology

The pelvic sidewalls are composed of a horseshoe shaped muscular sling covered with pelvic fascia. The iliopsoas muscles form the walls of the false pelvis while the obturator internus and piriformis muscles form the walls of the true pelvis. The pelvic floor is a fibromuscular diaphragm formed from the paired levator ani muscles anteriorly and the paired coccygeal muscles posteriorly. The levator ani muscle arises from the superior and posterior aspects of the pubis, the pelvic fascia covering the obturator internus muscle and the inner surface of the ischial bone and ischial spine. It inserts into the perineal body, coccyx and the anococcygeal body. The levator ani is divided into three groups of muscles. The anterior group (levator prostate or sphincter vaginae) forms a sling around the prostate and vagina and inserts into the perineal body. The middle group (puborectalis) forms a sling around the junction of the rectum and anal canal and blends with the external anal sphincter....

The Donnan equilibrium system in muscle

An important advance towards an understanding of the inequalities in ionic distribution observed in muscle was made in 1941 when Boyle and Conway pointed out that the type of equilibrium for diffusible and nondiffusible ions characterized by Donnan might apply. In a Donnan system consisting of two compartments separated by a membrane, the concentration ratios for any diffusible ions must be equal at equilibrium, since the same membrane potential is common to all of them. Boyle and Conway (1941) showed experimentally that in frog sartorius muscle the relationship

Ventral Posterior Medialis and Internal Capsule Stimulation

The inhibitory mechanism of stimulation of the main sensory relay nuclei of the thalamus and internal capsule remains obscure, at least in detail. These structures are cephalad extensions of the dorsal columns extending upward through the nucleus Cuniatus and Gracilis from the spinal cord, stimulation of which is known to relieve pain. Our studies in the cat reveal that sectioning of the dorsal columns below the level of activation does not completely obliterate the pain-reducing effects of dorsal column stimulation, indicating an additional more central inhibitory mechanism (39). Complete deactivation of pain

Internal Morphology of the Spinal Cord and Brain in Stained Sections

Long tracts are color-coded beginning at the most caudal spinal cord levels (e.g., see Figures 5-1 and 5-2), with these colors extending into the dorsal thalamus (see Figure 5-30) and the posterior limb of the internal capsule (see Figures 5-31 and 5-32). The colorized spinal tracts are the fasciculus gracilis (dark blue), the fasciculus cuneatus (light blue)*, the anterolateral system (dark green),

ACYST Secca Sacral Nerve Stimulation Artificial Bowel Sphincter and Stimulated Graciloplasty

In the first half of the century, patients who were not candidates for sphincter repair underwent sphincter reconstruction with muscle transpositions involving either the gluteus maximus or gracilis. These techniques only met with moderate success because the static, striated muscle flaps were prone to fatigue with chronic contraction. The transposed muscle did not have any involuntary tone at rest, and patients had to perform awkward movements to achieve imperfect continence.

Stimulated Graciloplasty

The technique of stimulated graciloplasty involves the transposition of the gracilis muscle from the thigh to form a skeletal muscular ring around the anus with the distal portion anchored to the contralateral ischial tuberosity (Figure 6-10.1). Two phases are used in this procedure with the number of required operations dependent on the use of an optional stoma. Phase I consists of transposition of the muscle and implantation of the stimulator and the electrodes (Figures 6-10.2 and 6-10.3). Phase II involves 8 weeks of muscle conditioning with increasing levels of neuromuscular stimulation. The use of a diverting stoma requires additional operative intervention for creation and closure. Upon completion of phase II, the patient is able to control continence with the use of an external magnet. The patient can switch the neurostimulator on, causing the muscle to contract, and off, causing the muscle to relax. Figure 6-10.2. Intraoperative view of the gracilis transposition for sphincter...

History of muscle transplantation

Soon recognized the potential of functioning muscle transplantation, whereby a muscle is not only revascularized in a new site but made to contract or function. In 1970, Tamai and colleagues 3 reported the successful transplantation of the rectus femoris muscle to the forelimb in a canine model using microneurovascular techniques. Electrophysiologic and clinical evidence of muscle contraction and function was presented. This formed the basis for ongoing research and development in this field. In 1973 at the Sixth People's Hospital in Shanghai, microsurgeons transplanted the lateral portion of the pectoralis major muscle in a patient with Volkmann's ischemic contracture 4 . This, in fact, was the first successful clinical application of functioning muscle transplantation. Remarkably, a good range of finger motion and substantial grip force were demonstrated. Confirmatory research was further performed in 1996 by Kubo and colleagues 5 , who demonstrated a virtual normal histologic...

Richard N Villar and Nicola Santori

Soft tissue structures of the hip joint arise from the same undifferentiated mesenchyme and similarly undergo a progressive development. By the 11th week of gestation, the capsule, internally lined with synovial cells, the labrum glenoidale, and the ligamentum teres, is well differentiated. The capsule, initially very thin, becomes progressively pluristratified, gaining thickness and strength. It is generally considered the most important structure contributing to hip stability. Joint, and consequent capsular, laxity may occur in either sex, but is more frequent in female subjects.2-4 The labrum increases the depth of the acetabular cavity and progressively takes on a fibrocartilaginous structure during development. femoral head to the medial border of the acetabular fossa behind the transverse ligament. It provides stability and restraint during the early phases of hip development. Furthermore, it gives mechanical support to the artery of the ligamentum teres or foveolar artery. This...

Operative technique of functioning muscle transplantation to the extensor aspect of the forearm

A surgical procedure for extensor muscle reconstruction follows the basic pattern of that described for the flexor surface. The degree of excursion required is less on the extensor aspect nevertheless, appropriate fixation points and muscle tension are essential. The authors prefer the gracilis muscle for extensor reconstruction for the same reasons outlined in the section on volar reconstruction. The main indications are direct trauma, tumor resection, Volkmann's ischemic contracture, or, in the case to be described, nerve damage. A 10-year-old girl presented with progressive loss of finger and thumb extension. She had neurofibromatosis and was being followed for this. Over the previous 6 months, she noted The gracilis muscle was harvested from the thigh and transplanted to the extensor surface. The extensor musculature, which is normally innervated by the posterior interosseous nerve, was thin, pale, and nonfunctional. The authors used the lateral epicondyle and the long extensors...

Adult brachial plexus injuries

Currently, Doi 28 and others have used this concept of extraplexal motor axons to reinnervate healthy (ie, not previously paralyzed) muscles from the leg, such as the gracilis muscle, or opposite trunk, such as the latissimus dorsi, that are surgically redeployed by the free microvascular transfer technique introduced by Manktelow and McKee 29 . They have overcome, to a certain degree, the difficulties inherent in trying to restore function in forearm flexor muscles located 15 to 18 in distal to the site of nerve reconstruction by inserting a healthy muscle and reinnervating it in a manner that shortens the time between denerva-tion (at transfer) and reinnervation by the selected motor nerve.

Chapter References

Costa e Silva, J.A. and De Girolamo, G. (1990). Neurasthenia history of a concept. In Psychological disorders in general medical setting (ed. N. Sartorius, D. Goldberg, G. de Girolamo, J. Costa e Silva, Y. Lecrubier, and U. Wittchen), pp. 69-81. Hogrefe and Huber, Bern. 32. Ustun, T.B. and Sartorius, N. (1995). Mental illness in general health care an international study. Wiley, Chichester.

Ultrasoundguided Injections

FIGURE 19 (A) Layering echogenic air bubbles within hip joint capsule (arrows). (B) Diagram. Source Courtesy of Henning Bliddal M.D., The Parker Institute, H S Frederiksberg Hospital, Copenhagen, Denmark. FIGURE 19 (A) Layering echogenic air bubbles within hip joint capsule (arrows). (B) Diagram. Source Courtesy of Henning Bliddal M.D., The Parker Institute, H S Frederiksberg Hospital, Copenhagen, Denmark.

S Evidence statements

Dantrolene sodium - One non-randomised and two randomised crossover trials compared dantrolene sodium against placebo344-346 (Ib). Two of the trials reported no differences between the groups, whilst data from the third trial was not reported adequately. No serious adverse events were reported in any of the trials. One further randomised crossover trial compared dantrolene sodium to diazepam and placebo.347 The results showed that both dantrolene sodium and diazepam were superior to placebo on measures on spasticity, reflexes and clonus. However, dantrolene sodium was reported to have a negative effect relative to diazepam and placebo on both hip flexor strength and deltoid strength.

Experience at Shriners Hospital for Children

Four weeks postimplantation, subjects participated in four weeks of strengthening and conditioning of the implanted muscles, followed by 17 to 22 weeks in which the focus was on programming of the upright mobility strategies and training for their functional use. Goals included achieving the transitions between sitting and standing, swing-through and or reciprocal gait with a walker or crutches, and prolonged standing. For reciprocal gait, swing was achieved through stimulation to the iliopsoas, biceps femoris, and or the tibialis anterior to create a flexor withdrawal response. Additional training goals included advanced activities, such as ascending and descending stairs (Figure 17.5A) and the achievement of subject-specific goals (Figure 17.5B). Bilateral ankle-foot orthoses were worn for all upright mobility activities.

Influence of Gender on Arteriolar Function in Hypertension

Females prior to menopause are much less susceptible to hypertension and other cardiovascular diseases than males, indicating that gender has a protective effect in these disorders and that female sex hormones can offset some of the alterations in arteriolar function that may occur with hypertension in males. For example, flow-induced arteriolar dilation is significantly reduced in male spontaneously hypertensive rats compared to females, because of the loss of the nitric oxide (NO)-mediated portion of the response. This impairment of the NO-mediated component of flow induced dilation results in a maintained elevation of wall shear stress in the male rats, suggesting that female sex hormones play an important role in maintaining NO-dependent vasodilator responses and in preserving the regulation of arteriolar shear stress by nitric oxide. Arteriolar dilation in response to increases in perfusate flow is also impaired in isolated gracilis muscle arterioles of ovariectomized female...

Postoperative Treatment

The iliopsoas lies anterior to the hip capsule and moves lateral with hip flexion, abduction, and external rotation. As the hip is extended, adducted, and internally rotated, the tendon moves in a medial direction. FIGURE 12.3. The iliopsoas lies anterior to the hip capsule and moves lateral with hip flexion, abduction, and external rotation. As the hip is extended, adducted, and internally rotated, the tendon moves in a medial direction.

Physical Exam Key Points

Check long bones for point tenderness (fracture, osteomyelitis). Check joints for warmth, tenderness, effusion, or restriction of full range of motion. Hip pathology manifests on exam with the hip joint flexed, abducted, and externally rotated to decrease mean articular pressure. Observe for muscle atrophy and leg length discrepancy.

Urethral Dilatation Incision or Reconstruction

Weighed against the complication of developing urinary incontinence. Curative therapy ranges from transurethral incision of the urethra to various forms of urethral reconstruction depending on the degree (mucosal vs transmural) and the area involved. For urethral reconstructions without bladder neck involvement, there is usually sufficient tissue of the anterior vaginal wall to use as pedicle flaps for reconstruction. If the vaginal tissue is extensively scarred, ischemic, or atrophied, other potential donor sites should be considered. These may include labial and perineal pedicle flaps, and rarely the use of rectus and gracilis pedicle flaps. We prefer to use buccal mucosa grafts (Figure 10-2.1) for urethral reconstruction in women when the anterior vaginal wall tissue is not applicable for reconstruction or the urethral defect is too large. This obviates the more disfiguring and morbid complications of muscle flaps or anterior bladder flap repairs (Barnes' bladder flap...

Side Effects And Complications

The principal risk to periarticular percutaneous procedures is leak of bone cement into the joint space. Upon fluoroscopic detection of such a leak, the injection should be stopped immediately with the hip joint mobilized to flatten the articular cement prior to complete solidification. In our experience, this leak was associated with a striking transitory upsurge in pain, which, surprisingly, did not prevent eventual pain relief and improvement in walking (4). However, a case of rapid chondrolysis of the hip, appearing after the intra-articular leakage of cement and requiring hip replacement, has been reported (6). This event suggests a direct chondrolytic effect of the acrylic cement.

General Aspects and History

Cx cortex EM eminentia mediana GD gyrus dentatus HI hippocampus LC locus coeruleus NDX dorsal nucleus of the vagal nerve NG nucleus gracilis NTS nucleus of the tractus solitarius PAG periaqueductal gray PeV peri-ventricular nucleus of the hypothalamus. Cx cortex EM eminentia mediana GD gyrus dentatus HI hippocampus LC locus coeruleus NDX dorsal nucleus of the vagal nerve NG nucleus gracilis NTS nucleus of the tractus solitarius PAG periaqueductal gray PeV peri-ventricular nucleus of the hypothalamus.

Systems for Suspension Cells or attached cells on microcarriers

Gas Sparger

Environment accurately in real time and control it automatically. This has allowed the sensor, controller and bioreactor manufacturer Applikon, collaborating with the bag manufacturer Stedim, to bring to market the Appliflex system, which appears similar to the Wave system but has in situ pH, DO and temperature sensors interfaced with a controller that allows feedback control of the culture environment. At the time of writing, Appliflex systems are only available for volumes up to 50 litres. A similar system has also been introduced recently by Sartorius, the product of a collaboration with Wave Switzerland.

Obturator Nerve Entrapment Description

Femoral Nerve Thickening

Understanding the anatomy of the obturator nerve and its relationship with the adductor muscles is helpful for understanding the syndrome and for surgical planning. The classic description of the anatomic course of the obturator nerve comes from Gray's Anatomy.73 The obturator nerve forms from the convergence to the ventral divisions of the ventral rami of L2, L3, and L4 spinal nerves within the psoas major muscle. The nerve then descends through the psoas muscle to emerge from its medial border at the pelvic brim. The nerve then curves downward and forward around the wall of the pelvic cavity and travels through the obturator foramen, after which it divides into anterior and posterior branches. The anterior branch enters the thigh over the obturator externus muscle and the posterior branch through the fibers of that same muscle. The anterior branch innervates the adductor longus, gracilis, and adductor brevis muscles. It also gives an articular branch to the hip joint near its...

Osteitis Pubis Surgery

Surgery Osteitis Pubis

The available reports on soft tissue procedures are limited to case reports or small retrospective reviews. A case report by Wiley16 reported favorable results after surgically excising cortical avulsion of the gracilis tendon at the pubic symphysis. Miguel14 presented his results of adductor muscle release off the pubis bone with adjunctive drilling into the symphyseal bone. Thirty-three (68 ) of 48 athletes (mostly soccer players) who underwent this procedure returned to an acceptable level of sports and 6 (12 ) were failures. (hip joint region) Adductor gracilis tears

Osteitis Pubis Description

A review of the pertinent anatomy and biomechanics is important in understanding this vague entity called osteitis pubis. Joints are classified into three basic types synarthrosis, which are fibrous and rigid di-arthrosis, which are synovial and freely movable and amphiarthroses, which are slightly movable.3 The pubic symphysis is located between the two pubic bones. Articular hyaline cartilage lines the two joint surfaces, which are separated by a thick intrapubic fibrocarti-laginous disk. The disk has a transverse anterior width of 5 to 6 mm, anteroposterior width of l0 to l5 mm, and a central raphe 7 The joint lacks a well-developed synovial lining, making it less susceptible to pathologic inflammatory changes such as those seen with ankylosing spondylitis and Reiter's syndrome.3 The pelvic architecture is essentially a continuous bony ring with three interspersed semirigid joints, two sacroiliac joints and one pubic symphysis, designed to dissipate undue forces. The thick inferior...

Dictums On Hip Arthroscopy

Patient Perineum Positioning Table

Regardless of the position or technique that is chosen for performing this procedure, several dictums should be thoroughly understood. First, a successful outcome is most clearly dependent on proper patient selection. A technically well-executed procedure fails if performed for the wrong reason. This may include failure of the procedure to meet the patient's expectations. Second, the patient must be properly positioned for the case to go well. Poor positioning ensures a difficult procedure. Third, simply gaining access to the hip joint is not an outstanding technical accomplish ment. The paramount issue is accessing the joint in as atraumatic a fashion as possible. Because of the constrained architecture and dense soft tissue envelope of the hip joint, the potential for inadvertent iatrogenic scope trauma is significant and, perhaps to some extent, unavoidable. Thus, every reasonable step should be taken to keep this concern to a minimum. Perform the procedure as carefully as possible...

T Kevin Robinson And Karen M Griffin

Posterior Femur Glide

Gluteal isometrics may decrease overactivity of the iliopsoas and provide a decrease in anterior hip pain. FIGURE 17.20. Gluteal isometrics may decrease overactivity of the iliopsoas and provide a decrease in anterior hip pain. tionally, isometric contraction of the antagonistic muscle group may inhibit spasms and promote pain relief. Gluteal isometrics may decrease overactivity of the iliopsoas and provide a decrease in anterior hip pain (Figure 17.20) (Appendix B). Very little posteroanterior movement of the femoral head takes place within the acetabulum, but anterior and posterior glides can also be beneficial for the painful hip joint (Figure 17.24). It can also be used as an accessory movement at the limit of physiologic range when a goal of treatment is to increase the range of motion of the joint.21 The pres- Joint range of motion is normalized by restoring capsular extensibility. Limitation of hip flexion and internal rotation commonly occurs because of posterior...

The active transport of ions

Squid Axon Sodium Replacement Solution

The Donnan equilibrium hypothesis required that the muscle membrane should be completely impermeable to sodium. When the radioactive isotope 24Na became available, this was soon found not to be so, for about half of the intracellular sodium in the fibres of a frog's sartorius muscle turned out to be exchanged with the sodium in the external medium in the course of one hour. Moreover, experiments on giant axons from squid and cuttlefish showed that after dissection there was a steady gain of sodium and loss of potassium that if not counteracted would eventually have led to an equalization of the sodium and potassium contents of the axoplasm. It became clear that in actuality the resting cell membrane does have a finite permeability of Na+ ions, but that the inward leakage of sodium is offset by the operation of a sodium pump which extrudes sodium at a rate which ensures that in the living animal Na is kept roughly constant. As far as sodium and potassium are concerned, the resulting...

Neurovascular Structures

Lateral Femoral Circumflex Artery

The femoral neurovascular structures (nerve, artery, and vein) exit the pelvis under the inguinal ligament halfway between the anterior superior iliac spine and the pubic tubercle (Figure 6.6). They are relatively anterior to the hip joint, with the nerve being the most lateral. These structures lie on the anterior surface of the iliopsoas muscle, and thus the muscle separates the femoral neurovascular structures from the hip. Rectus femoris reflected & direct heads Pectineus Iliopsoas Adductor magnus Adductor longus Adductor brevis Gracilis Rectus femoris reflected & direct heads Pectineus Iliopsoas Adductor magnus Adductor longus Adductor brevis Gracilis

Clinical Course of Ankylosing Spondylitis

Several clinical indices were proposed to assess the disease activity during the time course of AS or for the evaluation of treatment response, as the correlation with laboratory parameters of inflammation is only weak. The most important and widely accepted indices were developed by a group of rheumatologists in Bath, England. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) mainly refers to both pain and stiffness of the spine and peripheral joints. The degree of functional impairment during the patient's daily activities is evaluated by the Bath Ankylosing Spondylitis Functional Index (BASFI) and the Bath Ankylosing Spondylitis Metrology Index (BASMI), which consist of several parameters for spinal and hip joint mobility (16).

Microsurgical technique

Arthroscopic Brachial Plexus Neurolysis

More effectively than will sensory nerve grafts. Although sensory nerves are more readily expendable than their motor counterparts, the routine practice of using sensory nerve grafts to reconstruct critical motor nerve defects may warrant reappraisal. Motor nerves to expendable muscles such as the latissimus dorsi, medial or lateral gastrocnemius, vastus lateralis, and gracilis are among the candidate donor nerves that may be harvested with minimal donor morbidity. However, donor site morbidity and available length of nerve tissue may continue to limit the use of motor nerve grafts to reconstruct motor defects. Further investigation is needed to determine whether the benefits of motor nerve grafts are needed. Future strategies may include the use of motor nerve allografts or the development of nerve conduits that contain motor-derived Schwann cells.

Internal membrane systems

The next question to arise is, how does excitation at the cell surface cause release of calcium ions inside the fibre The first step in the solution of this problem was the demonstration by A. F. Huxley and R. E. Taylor that there is a specific inward-conducting mechanism located at the Z line in frog sartorius muscles. (We shall examine the striation pattern in detail later. But here it is worth noting that the markedly birefringent A bands alternate with the less birefringent I bands, and that a thin dense line, the Z line, bisects the I bands. Fig. 10.7 shows the whole pattern.) Fig. 10.4. The internal membrane systems of a frog sartorius muscle fibre. From Peachey (1965). Fig. 10.4. The internal membrane systems of a frog sartorius muscle fibre. From Peachey (1965).

Developmental Dysplasia

A 37-year-old woman presented with a 4-year history of progressively worsening right hip pain. There was no history of injury or precipitating event she simply began experiencing discomfort that had worsened over recent months. Twisting maneuvers were especially painful. Her examination findings suggested that her hip joint was the source of pain. Radiographs revealed evidence of modest underlying dysplasia but were otherwise unremarkable (Figure 15.3A). Magnetic resonance imaging (MRI) was also unremarkable. She then underwent 6 months of continued activity restriction as well as various trials of oral antiinflammatory medications and physical therapy without improvement. She obtained pronounced temporary alleviation of her symptoms from a fluoroscopically guided intraarticu-lar injection of anesthetic.

Selection of free flaps

It is important to minimize morbidity at the donor site. The vast array of free flaps available in the armamentarium of the reconstructive surgeon allows the donor site to be chosen based on the skin color, texture, and the components missing from the recipient site. Composite flaps can be harvested with different tissue components raised on different perforators of the same source artery. For example, the anterolateral thigh flap enables multiple components to be raised on different perforators from the lateral femoral circumflex artery, including skin, deep fascia, the vastus lateralis, rectus femoris and tensor fascia lata muscles, and iliac crest, enabling the accurate Gracilis flap The gracilis flap is based on the medial circumflex artery and vein, and can be harvested as a muscle-only or musculocutaneous flap for coverage of small to medium-sized defects. The pedicle length is typically 6 to 8 cm, and the flap can also be used for functional reconstruction of the forearm to...

Enterourinary Fistula

Tic option in high-risk diverticulitis patients. However, fecal diversion is often required for recurrent urinary tract infections. Nonetheless, some patients will present complete healing of the fistulous tract, and requirement for resection will depend on the nature of the colonic pathology. Iatrogenic enterourinary fistulas are often a consequence of surgical procedures such as prostatectomies, resection of rectal lesions, hysterectomy, laparoscopic inguinal hernia repair, and other pelvic operations. Radiation therapy for gynecologic or urologic malignancies may lead to progressive bowel injury culminating with perforation and often fistulization. A common example is the development of rectourethral fistula postradiation therapy of prostate cancer. This complex problem presents as ure-thral elimination of gas and stool as well as recurrent urinary sepsis. Diagnostic modalities include retrograde urethrogram and proctoscopy. The rectum is often inflamed and the mucosa friable with...

Operative technique of muscle transplantation to the arm for biceps function

Fig. 13. (A) Preoperative view shows lack of digital and thumb extension. (B) Gracilis muscle to replace denervated muscle secondary to a nerve tumor is shown. (C) Postoperative view with full extension of fingers and thumb. The operative procedure is again performed by two teams. The arm is prepared with an incision providing access to the acromion proximally, the brachial artery and the accompanying vein at the junction of the upper and middle thirds of the arm, and, finally, the distal biceps tendon and the bicipital aponeurosis inserting onto the ulna. The gracilis muscle is harvested and transplanted to the arm. It is secured proximally to the acromion, and the vascular and neural repairs are then performed. In the arm, end-to-side arterial repair and end-to-end venous repair are preferred. The musculocutaneous nerve is then coapted to the nerve to the gracilis. The muscle is placed under appropriate tension. This is accomplished by putting the elbow in full extension and then...

Other Differential Diagnoses Of Extraarticular Hip Pain

Several other diagnoses must be considered in patients with groin pain, including other musculoskeletal disorders, as well as more severe visceral problems. Problems that we have encountered in patients with inguinal pain include inflammatory bowel disease, prostatitis, aseptic necrosis of the hips, herpes, pelvic inflammatory disease, and rectal or testicular can-cer.101 These other possible diagnoses emphasize the importance of a detailed, careful history and physical examination. Musculoskeletal syndromes commonly considered in the differential diagnosis of lower abdominal or groin pain in the athlete include adductor injuries,102 piriformis and hamstring syndromes,65'102-104 snapping hip syndrome,101 iliopsoas tendonitis,105 iliotibial band syndrome,102 sacroiliac sprain,96 osteitis pubis,16 stress fractures,106 soft tissue injuries,101 contusions,105 bursitis,107 and myositis ossificans.96

Steve A Mora Bert R Mandelbaum Levente J Szalai Nicholas D Potter Archit Naik Jeff Ryan and William C Meyers

The task of diagnosing and managing extraar-ticular causes for hip and groin pain represents one of the greatest challenges in sports medicine. The differential diagnosis for hip and groin pain is broad and includes intraarticular hip disorders, acute and chronic muscular tears, pubic symphysis disorders, snapping hip syndrome, peripheral nerve entrapment, and abdominal wall abnormalities. Nonmusculoskeletal etiologies should also be considered these include urologic disease, gynecologic disease, gastrointestinal problems, infections, and tumors. Also complicating the clinical picture is the nature of groin symptoms, which may be vague, confusing, and generalized around the hip joint, thigh, and abdomen regions. The ambiguous constellation of symptoms can be partly explained by a complex pain referral pattern around the groin and the hip region. These problems are unfortunately frequently misdiagnosed and appropriate treatment often delayed. It is evident that the evaluation of these...

Treatment of Complex Rectovaginal Fistulas

Onlay Patch Cardiac

The area and to separate the two suture lines. Grafts of omentum, gracilis, sartorius, gluteus maximus, rectus, and bulbocavernosus muscle have been described. The bulbocavernosus muscle transposition is most frequently reported (Figure 13-2.5). The procedure is performed with the patient in the lithotomy position and a transperineal incision is made between the anus and vagina. The rectum is dissected from the vaginal wall, and both defects are sutured closed. A vertical incision is made over one of the labia majora, and skin flaps are created. The bulbocavernosus muscle and associated fat pad are mobilized and tunneled through a subcutaneous space to lie between the two closures. The vascular supply to this flap is the perineal branch of the pudendal artery. The gracilis transposition is advocated at our institution because of the larger size, length, and bulk of this muscle and the ease of its mobilization (Figure 13-2.6). After undergoing mechanical and antibiotic bowel...

Traction fixation devices

Occasionally, patients may present with ipsilat-eral cruciate ligament injury and hip joint pathology. Most commonly, these are the result of previous motor vehicle accidents. This author has performed hip arthroscopy using the standard distraction method in eight patients who have undergone previous ipsilateral cruciate ligament reconstruction without any untoward effects. However, it is recommended that the reconstructed knee ligament be fully matured before hip arthroscopy. Alternatively, a distal femoral traction pin may be appropriate in conjunction with a recent ipsilateral knee injury or reconstructive surgery.

Metabolism of skeletal muscle general features

In some animals, individual muscles are fairly uniform in their fibre type. In the rat, for example, there are some muscles which are composed almost entirely of red or white muscle fibres. For instance, the soleus muscle in the calf is used during movement such as running, and it is composed of consistently slow-twitch fibres. The adductor longus muscle in the thigh plays an intermittent role in maintaining posture and is a mainly fast-twitch muscle. In humans, most muscles are composed of a variety of fibre types. The composition of any particular muscle is not the same in everybody some people have a preponderance of oxidative fibre types, some a preponderance of white, fast-twitch fibre types. This pattern is inherited to some extent. This is one reason why some people are naturally better than others at certain types of athletic events for instance, someone with a preponderance of oxidative fibres will be better at endurance exercise than someone with more white, glycolytic...

Neurovascular Traction Injury

It is worthy to note, when considering the amount of distraction of the hip (approximately 1 cm), that this proportionately represents a small change relative to the overall length of the sciatic and femoral nerves. Perhaps some nerves are simply more at risk for injury. However, currently there are no parameters by which to define this circumstance. Some patients with hip joint pathology may have coexistent radicular or neurologic-type pain. For these patients, it is especially prudent to offer coun

Functioning free muscle transplantation

And subsequent neurorraphy of the muscle's motor nerve to a recipient motor nerve for reinnervation. The use of FFMT in brachial plexus reconstruction is another example of the application of neurotization and it has been shown to be effective and has become increasingly popular. The gracilis myocutaneous FFMT is the best choice for the donor muscle in brachial plexus reconstruction 26-28 . The most common extraplexus donor nerves include the XI, the IC, and the CC7, which all require a two-stage procedure elongation with a nerve graft (cable nerve grafts or vascularized ulnar nerve graft) at the first stage followed by an FFMT at the second stage 26-30 . The Ph nerve can be also used as a neurotizer. Intraplexus donor nerves include part of the ulnar nerve, part of the median nerve, or more proximally from the infraclavicular or suprascapular nerves, which require nerve elongation and FFMT in a two-stage procedure. The results from FFMT are more satisfactory than those provided by...

Specific movements and positions that reproduce the symptoms

The upper lumbar region (L1, L2 and l3) controls the iliopsoas muscles, which can be evaluated by testing resistance to hip flexion. While seated, the patient should attempt to raise each thigh while the physician's hands are placed on the leg to create resistance. Pain and weakness are indicative of upper lumbar nerve root involvement. The L2, L3 and L4 nerve roots control the quadriceps muscle, which can be evaluated by manually trying to flex the actively extended knee. The L4 nerve root also controls the tibialis anterior muscle, which can be tested by heel walking.

Case

A 17-year-old boy presented 2 years following closed treatment of a posterior column fracture of the right acetabulum. He had developed progressive mechanical hip joint symptoms including pain, catching, and a sensation of giving way, with discomfort localized to the groin area. Radiographs revealed changes consistent with his previous fracture and areas suggestive of in-traarticular loose bodies (Figure 2.1A). Multiple cartilaginous and osseous loose bodies were confirmed by double-contrast arthrography followed by CT scan (Figure 2.1B). At arthroscopy, multiple loose bodies were identified (Figure 2.1C). Many were too large to be retrieved through large-diameter cannulas but could be removed free-hand and with extra-length pituitary rongeurs.

Diphyllobothriases

The main incidence of diphyllobothriases in man in Russia is due to D. latum infestation with synanthropic foci (Klebanovski 1980, 1985). The intermediate hosts are Copepoda (Crustacea) and freshwater fish - pike, perch, salmon, trouts, and eel. Even in sparsely populated regions of Siberia, such as Karim lakes system in the western riverside of the Konda (HMAD), plerocercoid larvae were found in 92 of pikes in lakes that were close to villages and in 7.1 of pikes in lakes practically not visited by man (Klebanovskii 1985). Synanthropic foci of D. latum infection are the most intensive in the middle and middle-lower reaches of the West and the East Siberia great rivers (but in the lower reaches of the Irtish river) (Klebanovskii 1985). The prevalence of D. latum infection in the population of middle reaches of the Ob river in the 1970s was 10 . In aboriginal populations (Komi, Hanti) of the Ob middle-lower reaches it was 43.6 and was only 25-7 in the lowest reaches of the river...

Ureter

The ureters are paired, thick muscular tubes with a lumen of approximately 3 mm in diameter and are 24 to 30 cm in length. They originate at the renal pelvis and function to propel urine from the kidney to the bladder. In approximately 1 of the population, the ureter is duplicated. Duplications of the ureter are characterized as partial or complete. In partial duplications, the second ureter joins the first before reaching the bladder. In complete duplications, both ureters travel side by side to the bladder. In the abdomen, the ureters lie on the medial surface of the psoas major muscle, within the retroperitoneum. The right ureter lies underneath the terminal ileum, cecum, appendix, and ascending colon, and their mesenteries. The ovarian vessels cross the right ureter at its midsection. The left ureter is adherent to the underside of the mesentery of the descending and sigmoid mesocolon, and is crossed by the inferior mesenteric and ovarian vessels. The inferior mesenteric artery is...

Inspection

Which places the hip in internal rotation. Sitting may be uncomfortable, especially if the hip is placed in excessive flexion. Rising from the seated position is especially painful, and the patient may experience an accompanying catch or sharp stabbing sensation. Symptoms are worse with ascending or descending stairs or other inclines. Entering and exiting an automobile is often difficult with accompanying pain as this loads the hip in a flexed position along with twisting maneuvers. Dyspareunia is often an issue due to hip joint pain this is commonly a problem among female patients, but may be a difficulty for male patients as well. Difficulty with shoes, socks, or hose may simply result from pain or may reflect restricted rotational motion and more advanced hip joint involvement.

NO and Vasodilation

(flow, acetylcholine, bradykinin, and so on), the vascular bed studied (coronary, cremaster, gracilis, mesentery), the species (human, rat, mouse, hamster), and more recently, the number of endothelial-smooth muscle interconnections (i.e., myo-endothelial gaps). In eNOS (- -) mice, the local vasodilatory actions of acetylcholine or flow induced changes in blood flow are not diminished, because of compensation by upregulation of nNOS, endothelium-derived hyperpolarizing factor (EDHF), and vasodilatory prostaglandins 1, 2 . However, the local vasodilatory action of histamine was absent from second order arterioles in eNOS (- -) mice 3 . These are only a few of the many examples highlighting some of the differential response to NO as aforementioned. Another theory imparting NO as an important factor in microvascular blood flow control is the concept that NO bound to hemoglobin in red blood cells can serve as a stable NO adduct for delivery at sites of resistance. Clearly NO binds to the...

Muscle Strength

Active range of motion and resisted active range of motion may also reproduce joint symptoms. However, when carefully interpreted, a distinction can be made between symptoms of a muscle strain and hip pain. This differentiation may be least clear with a strain of the hip flexors. In this setting, active hip flexion reproduces pain while passive flexion should not.

Special Tests

With the patient supine, the Patrick or Faber test is performed by crossing the ankle over the front of the contralateral knee and then forcing the knee of the involved extremity down on the table. This combination of flexion, abduction, and external rotation stresses the sacroiliac (SI) joint, and when injury or inflammation is present, this movement markedly enhances symptoms localized to the SI area. This same maneuver can irritate the hip joint as well, but with distinctly different localization of symptoms. FIGURE 3.20. With the patient supine, the Patrick or Faber test is performed by crossing the ankle over the front of the contralateral knee and then forcing the knee of the involved extremity down on the table. This combination of flexion, abduction, and external rotation stresses the sacroiliac (SI) joint, and when injury or inflammation is present, this movement markedly enhances symptoms localized to the SI area. This same maneuver can irritate the hip joint as...

Radiography

FIGURE 3.24. (A, B) An active straight leg raise, or especially a leg raise against resistance, generates compressive forces of multiple times body weight across the hip joint. Consequently, this is often painful, especially when there is even an mild degree of underlying degenerative disease. FIGURE 3.24. (A, B) An active straight leg raise, or especially a leg raise against resistance, generates compressive forces of multiple times body weight across the hip joint. Consequently, this is often painful, especially when there is even an mild degree of underlying degenerative disease.

Arteries

The abdominal aorta bifurcates at the L4 level to form the common iliac arteries. These pass infero-laterally to divide at the level of the pelvic brim into the external and internal iliac arteries. They lie anterior to the common iliac veins. The external iliac artery follows the iliopsoas muscle to pass under the inguinal ligament. It gives origin to the deep circumflex iliac and inferior epigastric arteries, which supply the anterior abdominal wall. It lies antero-lateral to the external iliac vein. The internal iliac artery supplies the pelvic viscera, buttocks, medial thighs and perineum. It passes postero-medially into the pelvis dividing into anterior and posterior divisions at the superior edge of the greater sciatic foramen. The anterior division gives rise to the umbilical, obturator, vesical, middle rectal, vaginal, uterine, internal pudendal and inferior gluteal arteries. The posterior division gives rise to the superior gluteal, iliolumbar and lateral sacral arteries.

Hip Anterior

FV femoral vein FA femoral artery at the division of the deep femoral artery FAb femoral artery branch (medial cinconflex femoral artery) PM pectineus muscle IPM ileopsoas muscle Longitudinal view of pes anserina. T tibia PAT pes anserina tendons, (gracilis, sartorius and semitendinosus) med medial aspect

Muscle selection

The authors have had experience with the gracilis, latissimus dorsi, tensor fascia lata, and pectoralis major muscle in this procedure. None is ideal, but they authors have found the gracilis to be most applicable to the upper extremity. The latissimus dorsi has marked differences in internal muscle fiber length, thus making placement and fixation quite difficult. The same applies to the pectoralis major, and the donor defect is not ideal. The authors have found the gracilis to be most suitable on the basis of its donor defect and its neurovascular and anatomical setup. The extent of contraction of the gracilis is more than adequate to provide sufficient excursion for finger flexion or extension and for elbow flexion or extension. It is the authors' preference for all functioning free muscle transfers to the upper extremity, and its harvest is described in detail elsewhere in this article.

Operative technique

This difficult and complex procedure is best performed by a two-team approach. The gracilis muscle is ideal for such a transfer from the anatomic and physiologic perspectives 20,21 . Because of extensive scarring and previous surgical debridement, the surgical preparation of the forearm can be difficult and tedious. The incision along the volar forearm should be carefully planned. In the proximal forearm, the incision should allow for adequate exposure of the medial epicondyle and the neurovascular recipient structures that are going to be used. In the distal forearm, anticipation of skin flap cover should be taken into consideration. This is required for coverage of the tendon repairs to facilitate tendon gliding (Fig. 4). In certain situations, it is helpful to have a degree of independence of finger flexion and thumb flexion. This may be possible with the use of the anterior interosseous nerve. The anterior interosseous nerve courses distally, giving off separate branches to the...

Thomas G Sampson

The problem of consistently introducing the arthroscope into the hip joint has been resolved if procedure is followed. The new tasks are to perform previously described open procedures requiring arthro-tomy with arthroscopy similar to the evolution of arthroscopic surgery in the knee and shoulder.

Hip Injections

Anesthetic injection of the hip is one of the most commonly requested and performed articular injection procedures in the modern interventional musculoskeletal radiology practice. This is primarily due to the superior accuracy of the fluoroscopically guided needle positioning and the proximity of the joint to the femoral neurovascular structures. Verification of intra-articular needle positioning can also be difficult without fluoroscopy due to the depth of the joint capsule. Fluoroscopic guidance is therefore crucial to determine the proper needle approach and to verify intra-articular needle position. Although many techniques and approaches have been described, an anterolateral approach to the hip joint is preferred. This technique is both effective and safe due to the relative avoidance of the femoral neurovascular bundle. The anterolateral approach to the hip joint is performed with the patient supine, utilizing single plane posterior-anterior (PA) fluoroscopy with the hip...

Michael Dienst

For the past two decades, different centers in Europe,1-19 the United States,20-37 and Japan38-40 have been contributing to the development of standardized techniques and specification of indications for arthroscopy of the hip joint (HA), with most authors advocating the use of traction.6,22,25,41 The technique of hip arthroscopy without traction, however, has been disregarded. Only a few investigators have presented their experiences using this procedure 9,11,13,34,35,42-44 More recent reports have proposed different advantages of the nontraction technique. Klapper et al. also emphasized the low complication rate of this pro-cedure.34 Although traction is required for inspection of the direct weight-bearing cartilage, the acetabular fossa and the ligamentum teres, arthroscopy without traction is ideally situated for evaluation of the hip joint periphery.13,43 Based on the classification of the arthroscopic compartments of the hip joint, the following review presents detailed steps on...

Case Examples

A 57-year-old female patient was referred with a 4-year history of progressive right hip pain. A diagnostic HA was performed 2 years ago without any significant pathologic intraarticular findings. However, analysis of the operative report revealed that only the central compartment of the hip joint was scoped under traction. The patient complained of a pain radiating in her right groin and anterior proximal thigh that

Imaging

Plain radiographs are usually normal and may be helpful to identify exostoses or a spur on the lesser trochanter as well as dysplasia or impingement. Magnetic resonance imaging (MRI) is best to document any thickening of the iliopsoas tendon or fluid in the bursa. Iliopsoas bursography may demonstrate the outline of the tendon as it snaps over the hip capsule and is a dynamic test.3 Elimination of the pain by a lidocaine injection in the bursa is a positive diagnostic test.

Conclusion

Arthroscopic iliopsoas tendon release has been described. It is a safe and effective way to treat coxa saltans interna and is reproducible. The results are better than the results of open surgery and have fewer complications. FIGURE 12.8. An example of a trifurcated iliopsoas tendon. FIGURE 12.8. An example of a trifurcated iliopsoas tendon. 3. Harper MC, Schaberg JE, Allen WC Primary iliopsoas bursog-raphy in the diagnosis of disorders of the hip. Clin Orthop 1987 221 238-241. 4. Dobbs MB, Gordon JE, Luhmann SJ, et al Surgical correction of the snapping iliopsoas tendon in adolescents. J Bone Joint Surg Am 2002 84(3) 420-424.

Muscular exercise

The relation between energy production (heat plus work) and creatine phosphate breakdown in frog sartorius muscles poisoned with iodoacetate and nitrogen. Each point represents a determination on one muscle after the end of a series of contractions, with different symbols for different types of contraction. From Wilkie (1968). Fig. 9.15. The relation between energy production (heat plus work) and creatine phosphate breakdown in frog sartorius muscles poisoned with iodoacetate and nitrogen. Each point represents a determination on one muscle after the end of a series of contractions, with different symbols for different types of contraction. From Wilkie (1968).

Management Strategy

Hip flexor strain (6) Iliopsoas tendonitis (2) false-negative interpretation, which is reduced to 8 with MRA. However, with MRA, the false-positive interpretation doubles from 10 to 20 , with overinterpretation of labral lesions being the principal source of false-positive results.19 Lecouvet et al. have also demonstrated MRI evidence of labral pathology among asymptomatic volunteers, and the incidence increases with age.20 Thus, surgeons must still rely more on their clinical assessment of the athlete rather than simply MRI findings. With the increasing awareness of hip joint injuries in athletes and an increasing number of investigative studies being performed, a significant number of false-positive findings are likely, which could potentially lead the surgeon astray. It is also likely that many athletes participating in contact and collision sports over a long career may demonstrate MRI evidence of hip pathology even in absence of symptoms. The following algorithm is proposed for...

Microsporidia

Although complete genome sequences of both C. parvum and C. hominis have been determined, their carbohydrate metabolism is not fully understood (Abrahamsen et al. 2004 Xu et al. 2004). Glycolysis appears to be the main energy metabolic pathway, as they lack a functional TCA cycle and oxidative phosphorylation, although some components of the respiratory chain are present (Abrahamsen et al. 2004 Xu et al. 2004). Interestingly the conversion of pyruvate to acetyl-CoA is catalysed by an atypical pyruvate NADPH oxidoreductase (PNO) that contains an N-terminal PFO domain fused with a C-terminal NADPH-cytochrome P450 reductase (CPR) domain (Rotte et al. 2001 Abrahamsen et al. 2004 Xu et al. 2004). Surprisingly, the same PFO-CPR fusion protein has been reported in Euglena gracilis (Rotte et al. 2001), a euglenozoan protist distantly related to apicom-plexa. However, Euglena PNO appears to be a mitochondrial protein, whereas the function and cellular location of Cryptosporidium PNO is...

Future Trends

The trend toward making microneurosurgery less invasive continues with advances in neuronavigation, and neuroendoscopy and refinement of skull base techniques and surgical approaches to minimize brain retraction. Robotics in microneurosurgery seems to be the next wave of technological innovation to minimize the invasiveness of standard techniques. Certainly, they cannot replace surgeons. Their primary use in neurosurgery would be dexterity enhancement with dampening of physiologic tremor. This may then allow one to operate through narrow corridors safely with the use of endoscopes. Surgery using robotic systems has already been applied in many surgical fields such as the Robodoc System (Integrated Surgical Systems, Davis, CA) for hip joint replacement surgery (51), and the da Vinci System (Intuitive Surgical, Sunnyvale, CA) for coronary artery bypass surgery (52). The NeuRobot telecontrolled micromanipulator system currently under development and in preliminary testing seems to be...

Ultrafiltration

Companies such as Millipore, Pall, Sartorius, and Schleicher and Schuell produce membranes and hardware for ultrafiltration. It is essential to use a system that can be scaled-up for the requirements of commercial manufacture. It is ideal to use a system that can also be scaled down to laboratory scale for use as a model for such activities as process validation and virus clearance validation. One such system is the Centrasette system from Pall (Figure 18.8), which can be used at very large scales (in the Centrastak) but is also supplied as a low volume Centramate system, using identical materials of construction and with an identical flow path, with a membrane size as small as 0.01 m2.

Pain Control

It should be explained to the patient that there will be pain from the surgical procedure, but also some muscular soreness in the operative leg. This soreness is related to manipulation of the hip, the traction, and distractive forces used during the arthroscopic procedure. Usually, there is soreness in the hip joint after the acute surgical pain has abated. Soreness due to the use of the perineal post for distraction is common with some patients. They typically describe it as feeling like they have ridden a horse and have soreness in their saddle area. Ankle soreness in the operative leg is related to the traction boot. It is reassuring for the patient to know that these various aches normally resolve in 5 to 7 days.

Activity Level

The activity level prescribed after hip arthroscopy is variable, depending on the pathology found at the time of surgery and the surgeon's preference. Generally, an assistive device such as crutches or a walker is recommended during the first week, with the patient bearing weight as tolerated. A normal gait pattern usually returns within this time frame, but patients should be encouraged to use their assistive devices until they see the physical therapist or return to the surgeon's office. Weight-bearing status may be more restricted in certain cases such as abrasion arthroplasty of the weight-bearing surface of the hip joint. FIGURE 18.2. Inspection of the wound demonstrates the position of the standard portals. These are placed lower than many patients expect when conceptualizing the location of their hip joint. FIGURE 18.2. Inspection of the wound demonstrates the position of the standard portals. These are placed lower than many patients expect when conceptualizing the location of...

Athletic Pubalgia

Algorithm For Testicular Pain

Various other terms have been used in the literature to describe what seems to be the same syndrome we have called athletic pubalgia. Those terms include Gilmore's groin, hockey groin syndrome, sportsman's hernia, osteitis pubis, snapping hip syndrome, gracilis syndrome, hockey goalie baseball pitcher syndrome, and a variety of muscle strains, tendonopathies, and bursitises. pect of the symphysis include the adductor muscles, pectineus, gracilis, obturator internus, quadratus femoris, and gluteus muscles. A series of ligamentous arches also exist between the pelvic bones, further stabilizing the joint. The syndrome of athletic pubalgia is common in highperformance athletes. The syndrome's features include disabling lower abdominal and inguinal pain at extremes of exertion. The pain progresses over months to years and involves the adductor longus tendons and the contralateral inguinal or adductor regions. The diagnosis of this syndrome is generally empiric. regularity, distinct fluid...

Rigidity

Rigidity affects both limb and axial musculature and contributes to the postural deformities seen in PD. The stooped or simian posture and lateral tilt of the trunk are common sequelae of axial rigidity. In some patients, severe forward flexion of the thoracolumbar spine occurs, a phenomenon known as camptocormia.24 It is controversial, however, whether camptocormia is due to rigidity of the iliopsoas and spinal muscles or a rare and extreme example of a typically parkinsonian postural deformity. A combination of rigidity and postural abnormality can result in involuntary flexion of the forearm, extension of the proximal and distal interphalangeal joints with flexion at the metacarpophalangeal joints (the striatal hand), and flexion at the knees. Common complaints of patients that can be attributed in part to rigidity include difficulty turning over in bed or standing up from a chair, and muscle cramps or pain

General Technique

Smith And Nephew Offset Gauge

The pathway of the anterior portal penetrates the muscle belly of the sartorius and the rectus femoris before entering the anterior capsule (Figure 10.12). At the portal level, the lateral femoral cutaneous nerve has usually divided into three or more branches. Consequently, the portal usually passes within several millimeters of one of these branches. Because of the multiple branches, the nerve is not easily avoided by altering the portal position. Rather, it is protected by using meticulous technique in portal placement. Specifically, the nerve is most vulnerable to a deeply placed skin incision that lacerates one of the branches. Therefore, the initial stab wound should be made carefully through the skin only. Sartorius M. Sartorius M. Rectus Femoris M.

Subjective Data

Extraarticular sources of hip pain can be the lumbar spine, sacroiliac joint, or sciatic nerve. Strains of certain muscles, such as the hip adductors or flexors, can also imitate hip joint symptoms. When deep tendinous involvement occurs, such as from the piriformis or iliopsoas tendon, it may be difficult to differentiate these symptoms from mechanical hip symptoms. Although uncommon, a femoral hernia also produces groin pain. The most specific indicator for hip joint pain is log rolling of the patient's leg. This action moves only the femoral head in relation to the acetabulum and the surrounding capsule. The absence of pain on log rolling does not preclude the hip as the source of symptoms, but the presence of pain with this ma neuver greatly raises the suspicion of mechanical joint pathology.

Assessment

Sensation The Right Hip

Of the hip, and decreased hip extension on the involved side. Normal gait uses multiplanar hip motion of 15 degrees of extension, 37 degrees of flexion, 7 degrees of abduction, 5 degrees of adduction, 4 degrees of internal rotation, and 9 degrees of external rotation4 (Figure 17.4). Ascending stairs requires the motion of a normal walking pattern with additional 67 degrees of flexion and creates a force of three times body weight. Standing on one leg creates a force of two and one-half times, while loads approaching eight times body weight occur in the hip joint during jogging, with potentially greater loads resulting from vigorous athletic competition5 (Figure 17.5). hip joint can tolerate a force of approximately 12 to 15 times body weight.6 Primary problems of symptomatic hip pathology may involve the soft tissue encasing the joint, the surrounding capsule, or the joint structure. The irritation and inflammation of the musculotendinous structures, bursae, or joint capsule can...

Traction

Chic Fracture Table

Slotted cannula allowing introduction of curved instruments into the hip joint. FIGURE 9.10. Slotted cannula allowing introduction of curved instruments into the hip joint. FIGURE 9.14. (A) The C-arm is beneath the patient's table and is brought to the level of the hip joint. The monitor sits across from the surgeon. (B) View of the C-arm from the surgeon's position anterior to the patient. Note it is out of the way of surgery. FIGURE 9.14. (A) The C-arm is beneath the patient's table and is brought to the level of the hip joint. The monitor sits across from the surgeon. (B) View of the C-arm from the surgeon's position anterior to the patient. Note it is out of the way of surgery.

Capsule

Dvorak and coauthors30 have reported that the Weit-brecht's retinacula can be seen on the posterosuperior aspect of the femoral neck when looking anteriorly from a posterior paratrochanteric portal. This is a flattened band reflecting from the fibrous capsule of the hip joint to the head and neck of the femur, present in 94.8 of male and 92.5 of female subjects. Nutrient arteries for the femoral head run through the retinacula. Noriyasu and coauthors31 have reported that there are two types of retinacula a complete band shape and a posterior membranous shape. A circular aperture between the pubofemoral and il-iofemoral ligaments sometimes joins the articular cavity with the subtendinous psoas (iliac) bursa. This structure separates the capsule from the iliopsoas muscle and is lined with synovium.

Neuromotor Control

Proprioceptive deficits routinely occur in conjunction with articular injuries. The acetabular labrum contains free nerve endings and sensory organs. It is believed that these free nerve endings contribute in no-ciceptive and proprioceptive mechanisms.16 The acetabular labrum also improves the stability of the hip joint by maintaining a negative intraarticular pres-sure.17 With injury to the labrum, this negative pressure is lost and stability of the hip is adversely affected, inhibiting normal motor response and decreasing neu-romuscular stabilization of the joint. The aim of pro-prioceptive retraining is to restore these deficits and assist in reestablishing neuromotor control. The elements necessary for reestablishing neuromuscular control are proprioception, dynamic joint stability, reactive neuromuscular control, and functional motor pathways. Joint positioning tasks early in the rehabilitative process can enhance proprioceptive and kines-thetic awareness.32 More advanced...

Conclusions

A comprehensive inspection of the hip joint requires the combination of hip arthroscopy with traction and hip arthroscopy without traction. Although traction is necessary for access to the central compartment for evaluation of the direct weight-bearing cartilage, ac-etabular fossa, and ligamentum teres, the periphery of the joint can best be seen without traction. 38. Ide T, Akamatsu N, Nakajima I Arthroscopic surgery of the hip joint. Arthroscopy 1991 7 204-211. 43. Dienst M, Goedde S, Seil R, Hammer D, Kohn D Hip ar-throscopy without traction in vivo anatomy of the peripheral hip joint cavity. Arthroscopy 2001 17 924-931. 44. Dienst M, Goedde S, Seil R, Kohn D Diagnostic arthroscopy of the hip joint. Orthop Traumatol 2002 10 1-14. 47. Dienst M, Seil R, G dde S, et al Effects of traction, distension and joint position on distraction of the hip joint an experimental study in cadavers. Arthroscopy 2002 18 865-71. 56. Majewski M Arthroscopic mobilisation of the hip joint in children and...

Physical Examination

The most important aspect of inspection is stance and gait. The patient's posture is observed in both the standing and seated positions. Any splinting or protective maneuvers used to alleviate stresses on the hip joint are noted. While standing, a slightly flexed position of the involved hip and concomitantly the ipsi-lateral knee is common (Figure 3.2). In the seated position, slouching or listing to the uninvolved side avoids extremes of flexion (Figure 3.3).

Patient Selection

Extraarticular injuries far outnumber intraarticu-lar problems in the hip region. Thus, it is best to temper the interest in performing an extensive intraartic-ular workup for every athlete with pain around the hip. However, in our study of athletes who underwent arthroscopy with documented pathology, in 60 of cases the hip was not recognized as the source of symptoms at the time of initial treatment, and the patients were managed for an average of 7 months before the hip was considered as a potential contributing source.5 The most common preliminary diagnoses were various types of musculotendinous strains (Table 13.2). Thus, it is prudent to at least consider possible intraarticular pathology in the differential diagnosis when managing a strain around the hip joint. Most important is thoughtful follow-up and reassessment when these injuries do not respond as expected.

Musculature

Anatomical Terms For Greater Trochanter

The hip musculature can be conceptualized as a superficial layer and a deep layer. The fascia lata covers the entire hip region including the three muscles that make up the superficial layer the tensor fascia lata, sartorius, and gluteus maximus (Figure 6.3). The fascia lata also splits to cover the deep and superficial surface of the tensor fascia lata and gluteus maximus encasing these muscles. The tensor fascia lata and the gluteus maximus insert as a continuation, forming the iliotibial band. The gluteus maximus also partly inserts into the proximal femur at the gluteal tuberos-ity. This fibromuscular sheath was described by Henry8 as the pelvic deltoid, reflecting the fashion in which it covers the hip much as the deltoid muscle covers the shoulder. Interestingly, the gluteus maximus is the largest muscle in the body, and the sarto-rius, which crosses two joints, although quite weak, is the longest. Sartorius Sartorius Posteriorly, the deep muscle layer includes the piriformis,...

Foot and Ankle

FIGURE 2 Iliopsoas tendon sheath injection. (A) Transverse sonogram obtained over the anterior capsule (c) of the hip in a patient with a snapping iliopsoas tendon. A small bursal fluid collection (*) is seen immediately superficial to the tendon. The iliopsoas tendon (arrow) is inhomogeneous-containing intrasubstance clefts. fh and p denote the femoral head and pubis, respectively. (B) Using a curved linear transducer and lateral approach, a 22-gauge spinal needle is advanced toward the deep surface of the iliopsoas tendon (t). (C) Improved visualization of the needle tip along the deep surface of the tendon is achieved by test injection of a small amount of local anesthetic. The presence of echogenic microbubbles along the deep surface of the tendon confirms needle position. (D) and (E) Longitudinal sonograms over the iliopsoas tendon before (D) and following (E) administration of anesthetic and corticosteroid. In (E), echogenic microbubbles (arrow) are seen to distribute along the...

Fluid extravasation

Glick was the first to report on the potentially serious complications associated with excessive fluid extravasation, especially into the abdominal cavity.2 All cases resolved without long-term sequelae, but one required paracentesis and ventilatory support overnight. Sampson subsequently reported nine cases of intraabdominal fluid extravasation.6 Contributing factors included long operative times, fresh acetabular fractures, and extraarticular procedures such as iliopsoas tendon release. They believed that switching to an outflow-dependent pump reduced the incidence of extravasation and the total amount of fluid necessary for performing arthroscopy. They emphasized that it is

Anterolateral Portal

The anterolateral portal lies most centrally in the safe zone for arthroscopy and thus is the portal established first for introduction of the arthroscope. It is positioned directly over the superior margin of the greater trochanter at its anterior border (see Figure 7.2). Accounting for the slightly anterior position of the femoral head resulting from femoral neck anteversion, this allows a relatively straight shot into the hip joint under fluoroscopic guidance in the anteroposterior (AP) plane. Care should be taken during portal placement to assure neutral rotation of the hip because excessive internal or external rotation alters the relationship of the greater trochanter with the femoral head.

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