Urologic manifestations of the iliacus hematoma syndrome.

Anticoagulated patients may have a characteristic syndrome of femoral neuropathy from an iliacus muscle hematoma. They may present with urologic signs and symptoms, including groin, flank and thigh pain, groin tenderness, an iliac fossa mass and hematuria. Urography may reveal an enlarged psoas shadow and hydronephrosis from ureteral obstruction. Prompt diagnosis is essential so that early operative decompression of the femoral nerve can be done. The urologist has an important role in the diagnosis and treatment of this syndrome.     

Neuropathy of the obturator nerve as a source of pain in soccer players]

Chronic inguinal and lower abdominal pain in high-performance athletes is common and often disabling problem. Diagnose and treatment is often difficult due to many anatomic structures in the inguinal and groin region that have the potential to cause pain. We report 52 cases of a chronic groin pain in soccer players due to fascial entrapment of the obturator nerve. All patients presented clinical symptoms and signs of post exercise groin, lower abdominal or medial tight pain and adductor muscles weakness and paresthesia in cutaneous distribution of medial thigh. Except clinical signs in the diagnosis of obturator neuropathy we used diagnostic local anaesthetic block and electromyography. In 52 patients the cause of chronic groin pain was obturator neuropathy and they were treated operatively. Surgical neurolysis provided the definitive cure of pain in 41 players.     

Lateral meniscus and lateral femoral condyle cartilage injury by retained cement after medial unicondylar knee arthroplasty

The authors experienced an unusual case of a patient with a complex tear of the lateral meniscus and adjacent lateral femoral condyle cartilage injury in the contralateral compartment by retained cement, possibly located at the posteromedial side of the medial tibial component after unicondylar knee arthroplasty. Arthroscopic partial meniscectomy and cartilage microfracture were successfully performed. Two small cement fragments were removed from the posterolateral compartment. A sharp pain in the lateral side disappeared postoperatively and posterior knee pain was much reduced.     

Dr Jacob Mackiewicz (1887-1966) and his sign

Dr Jacob Mackiewicz, a Jewish-Polish neurologist, described the cruralis phenomenon related to injury of the femoral nerve or of the fourth lumbar root. In 1912, only one year after graduation maxima cum laude from Moscow University, the 25-year-old Dr Jacob Mackiewicz described the cruralis phenomenon, regarded in the German and Slavic medical literature as the Mackiewicz sign: 'the patient lies prone, the examiner lifts the thigh in one hand, with the other hand, bends the patient's knee slowly; this manoeuvre causes severe pain in the anterior part of the thigh and over the groin. This manoeuvre indicates a femoral nerve injury'.     

Femoral nerve palsy secondary to traumatic pseudoaneurysm and iliacus hematoma

The authors report a case of traumatic femoral nerve palsy caused by a pseudoaneurysm of the iliolumbar artery and a iliacus muscle hematoma. This case report details not only the classic history and physical findings seen in patients such as this one, but also illustrates an unusual source of the hematoma and a discussion of its treatment. A 20-year-old man was assaulted and presented to the authors's institution with a 1-week history of severe pain in the left anterior thigh and groin, weakness in the left quadriceps muscle, and numbness in the anterior thigh and medial distal leg. Imaging studies demonstrated a large, 9.4 x 6.4 x 5.2-cm iliacus hematoma as well as a pseudoaneurysm originating from the left iliolumbar artery. The patient underwent angiographic embolization of the pseudoaneurysm followed by surgical evacuation of the hematoma. The embolization was performed before surgery to prevent any possible rebleeding from the pseudoaneurysm during evacuation of the hematoma. Femoral nerve palsy caused by traumatic iliacus hematoma is an infrequent diagnosis often missed because of its insidious presentation. In this case, embolization of the iliolumbar artery pseudoaneurysm followed by surgical evacuation of the hematoma resulted in a nearly full recovery of the femoral nerve as of the last follow-up examination.     

Management of persistent groin pain after transobturator slings

Prolonged groin pain after transobturator tape is uncommon. Three women reported groin pain that had not improved by 3 months postoperatively. Combined steroid and local anesthetic was effective for pain relief in all patients. The differential diagnosis of persistent groin pain after transobturator tape includes adductor muscle strain, osteitis pubis, obturator/groin abscess, structural adhesions, and inflammation, edema or nerve entrapment of the anterior branch of the obturator nerve. No side effects of treatment were noted. Patients that do not respond to local injection may require mesh dissection and excision.     

膝降动脉穿支蒂股内侧皮神经营养血管皮瓣的应用解剖

目的 为膝降动脉穿支蒂股内侧皮神经营养血管皮瓣提供解剖学基础.方法 在40侧动脉内灌注红色乳胶的成人下肢标本上,以股骨内侧髁为观测标志解剖观测:股内侧皮神经走行与分布;膝降动脉穿支与股内侧皮神经营养血管间的吻合关系.另1侧新鲜标本进行摹拟手术.结果 股内侧皮神经体表投影为腹股沟韧带中点与股骨内侧髁的连线;膝降动脉(髌下支)穿支于股骨内侧髁下缘上约4 cm,在股内侧肌、大收肌腱与股骨内侧髁所围成的三角形凹陷内穿过深筋膜至皮下,并分出众多的细小血管与股内侧皮神经的神经旁和神经干血管链(网)密切吻合,在大腿内侧形成顺沿股内侧皮神经纵轴的血管丛.结论 根据膝降动脉穿支与股内侧皮神经营养血管吻合关系,可形成膝降动脉穿支蒂股内侧皮神经营养血管皮瓣转位修复膝部软组织缺损.     

The medial circumflex femoral (gracilis) local perforator flap--a local medial groin perforator flap

The medial circumflex femoral(GRACILIS) perforator free flap has been previously used to capture the superior medial thigh skin territory. This can also be valuable as a local flap, especially for adjacent groin wounds that are not uncommon after vascular interventions. Uncomplicated healing without vascular compromise was achieved using this as a local flap in 4 recent cases. Because the gracilis muscular branches can be independently dissected from the musculocutaneous perforators, the muscle itself can be separately included to form a combined conjoint flap, where the muscle is specifically only used to wrap around and protect any exposed vascular structures while the cutaneous component simplifies skin wound closure. The axis of rotation of the medial circumflex femoral perforator local flap extends throughout the groin region and potentially to the lateral thigh. This is an ideal local perforator flap because the source pedicle has a consistent location already well known to most plastic surgeons, the boundaries of the potential skin territory are reliable and well defined, and the scar from closure of the donor site within the medial groin can be readily concealed by clothing.     

Migration of intrapelvic cement after total hip arthroplasty

Intrapelvic extrusion of cement during total hip arthroplasty is a frequent occurrence. We report a case in which the intrapelvic cement mass broke free 3 years after the primary procedure and migrated proximally to lie against the posterior abdominal wall, resulting in intractable groin pain. The patient was relieved of pain after removal of the cement mass.     

Total hip arthroplasty with ceramic-on-ceramic bearing failure from third-body wear

This article describes a new mechanism of failure of a ceramic-on-ceramic total hip arthroplasty (THA) due to fretting corrosion and failure of the Morse taper. A 46-year-old man with hip osteonecrosis underwent THA in 2006. A ceramic-on-ceramic, un-cemented THA with a titanium femoral component and metal-on-ceramic Morse taper was implanted. Two years postoperatively, he presented with swelling in his groin and a painless medial thigh mass. The thigh mass was diagnosed as an abscess. Incision and drainage was performed and resulted in a sinus tract that continuously drained copious amounts of seropurulent fluid. Two months later, the patient underwent irrigation, debridement, and explantation of his hip. Frozen sections showed no signs of infection. There was dramatic visible wear of the Morse taper and pieces of metal embedded in the ceramic. Permanent sections showed chronic inflammation and foreign body reaction. He subsequently underwent an uneventful re-implantation with a metal-on-highly-cross-linked-polyethylene THA. In this case, failure of the morse taper led to metal debris, which reacted with the ceramic and caused dramatic third-body wear. The thigh mass, which appeared to be an infection, proved to be a massive foreign body granuloma. Malfunction of the morse taper as reported in this case represents a possible failure mechanism of a ceramic-on-ceramic THA.     

Obturator-nerve palsy resulting from intrapelvic extrusion of cement during total hip replacement. Report of four cases

Obturator neuropathy is an infrequently identified complication of total hip replacement that may cause debilitating pain. There have been isolated reports of this complication in the literature, but only one case has been published in which intrapelvic cement was the causative agent. We are describing the cases of four patients with obturator neuropathy after total hip replacement, documented by electromyography and attributed to intrapelvic extension of cement. In each patient the source of the symptoms was not initially apparent. In three of the patients the extruded cement and obturator nerve were explored surgically. One of the three patients was improved by obturator neurectomy. Of the other two patients, both treated by excision of cement, only one was improved. The fourth patient was not treated. Persistent pain in the groin and thigh, intrapelvic cement visible on plain roentgenograms, and adductor weakness after total hip replacement suggest that this complication has occurred. Electromyography can confirm the presence of obturator neuropathy. Based on this limited series, excision of the extruded cement and preservation of the nerve should be attempted only when the nerve is grossly normal and functional as determined by electrical stimulation at the time of surgical exploration; otherwise, obturator neurectomy should be considered.     

Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh

Objectives  Mild pain lasting for a few days is common following mesh inguinal hernia repair. In some patients however, severe groin pain may appear months or even years postoperatively. The aim of this study was to report our experience of late-onset persisting severe postoperative groin pain occurring years after mesh hernioplasty. Methods  In a 9-year period, 1,633 patients (1,073 men), median age 63 years (range 19–88), underwent mesh groin hernia repair. Between 1.5 and 4 years postoperatively, six patients (0.35%) presented with severe chronic groin pain unrelieved by conservative measures and surgical exploration was essential. The patients’ records were retrospectively reviewed for the purpose of this study. Results  Ilioinguinal nerve entrapment was detected in four patients. The meshes appeared to be indistinguishable from the nerve and were removed along with the stuck nerve. New meshes were properly inserted. Mesh fixation on the periostium of the pubic tubercle by a staple was found in the other two patients. The staples were removed from the periostium in both patients. Neither hernia recurrence nor chronic groin pain was persisting in all six patients during a follow-up of 6–44 months postoperatively. Conclusion  From the results of this study, it appears that ilioinguinal nerve entrapment and/or mesh fixation on the periostium of the pubic tubercle are the causes of late-onset severe chronic pain after inguinal mesh hernioplasty. Mesh removal, along with the stuck ilioinguinal nerve and staple detachment from the periostium, are the gold-standard techniques if conservative measures fail to reduce pain.     

An evaluation of the cutaneous distribution after obturator nerve block.

In 1973, Winnie et al. introduced the inguinal paravascular three-in-one block, which allegedly provides anesthesia of three nerves--the femoral, lateral cutaneous femoral, and obturator nerves--with a single injection. This concept was undisputed until the success of the obturator nerve block was reassessed by using evidence of adductor weakness rather than cutaneous sensory blockade, the latter being variable in its distribution and often absent. We performed this study, therefore, to evaluate the area of sensory loss produced by direct injection of local anesthetic around the obturator nerve. A selective obturator nerve block with 7 mL of 0.75% ropivacaine was performed in 30 patients scheduled for knee surgery. Sensory deficit and adductor strength were evaluated for 30 min by using sensory tests (cold and light-touch perception) and the pressure generated by the patient's squeezing a blood pressure cuff placed between the knees. Subsequently, a three-in-one block was performed, and the sensory deficit was reassessed. The obturator nerve block was successful in 100% of cases. The strength of adductors decreased by 77% +/- 17% (mean +/- SD). In 17 patients (57%), there was no cutaneous contribution of the obturator nerve. The remaining 7 patients (23%) had an area of hypoesthesia (cold sensation was blunt but still present) on the superior part of the popliteal fossa, and the other 6 (20%) had sensory deficit located at the medial aspect of the thigh. The three-in-one block resulted in blockade of the lateral aspect of the thigh in 87% of cases, whereas the anteromedial aspect was always anesthetized. By use of magnetic resonance imaging in eight volunteers, we demonstrated that the obturator nerve has already divided into its two branches at the site of local anesthetic injection. However, the injection of blue dye after having simulated the technique in five cadavers showed that the fluid regularly spread to both branches. We conclude that after three-in-one block, a femoral nerve block may have been assessed as an obturator nerve block in 100% of cases when testing the cutaneous distribution of the obturator nerve on the medial aspect of the thigh. IMPLICATIONS: Previous studies reporting an incidence of obturator nerve block after three-in-one block may have mistaken a femoral nerve block for an obturator nerve block in 100% of cases when the cutaneous distribution of the obturator nerve was assessed on the medial aspect of the thigh. The only way to effectively evaluate obturator nerve function is to assess adductor strength.     

Obturator hernia: A case report and review of the literature

INTRODUCTIONAn obturator hernia is a rare condition but is associated with the highest mortality of all abdominal wall hernias. Early surgical intervention is often hindered by clinical and radiological diagnostic difficulty. The following case report highlights these diagnostic difficulties, and reviews the current literature on management of such cases.PRESENTATION OF CASEWe present the case of an 86-year-old lady who presented with intermittent small bowel obstruction, clear hernial orifices, and right medial thigh pain. Pre-operative CT imaging was suggestive of an obstructed right femoral hernia. However, intra-operatively the femoral canal was clear and an obstructed hernia was found passing through the obturator foramen lying between the pectineus and obturator muscles in the obturator canal.DISCUSSIONObturator hernias are notorious for diagnostic difficulty. Patients often present with intermittent bowel obstruction symptoms due to a high proportion exhibiting Richter's herniation of the bowel. Hernial sacs can irritate the obturator nerve within the canal, manifesting as medial thigh pain, and often no hernial masses can be detected on clinical examination. Increasing speed of diagnosis through early CT imaging has been shown to reduce the morbidity and mortality associated with obturator hernias. However, over-reliance on CT findings should be cautioned, as imaging and operative findings may not always correlate.CONCLUSIONA high suspicion for obturator hernia should be maintained when assessing a patient presenting with bowel obstruction particularly where intermittent symptoms or medial thigh pain are present. Rapid clinical and appropriate radiological assessment, followed by early surgery is critical to successful treatment.     

Prophylactic intramedullary fixation for bisphosphonate-related subtrochanteric stress fracture

Bisphosphonates are the most widely used medication to treat osteoporosis. Recent reports have documented an association between chronic bisphosphonate use and femoral insufficiency fractures. This article describes an 84-year-old woman with a diagnosis of osteoporosis treated with bisphosphonate medications for 9 years. She presented with left groin pain, and magnetic resonance imaging revealed a subtrochanteric femoral stress fracture. Operative and nonoperative management was discussed with the patient, and she chose to undergo prophylactic intramedullary nailing of the left femur. Six months postoperatively, she was asymptomatic and ambulating without assistive devices.This article describes successful management of a bisphosphonate-related femoral insufficiency fracture. The presence of groin or thigh pain in a patient taking bisphosphonates should alert the physician to the possibility of insufficiency fracture of the proximal femur, and plain radiographs should be obtained. If these radiographs show lateral cortical thickening, consideration should be given to prophylactic intramedullary femoral nailing. The risks and benefits of prophylactic fixation vs conservative management should be discussed with the patient. A recent series showed a high failure rate with conservative treatment of these fractures. A dialogue with the primary care physician should be initiated to determine the necessity of bisphosphonate therapy, and, if deemed necessary, an alternative class of medications should be considered.     

The femoral neuralgia syndrome after arterial catheter trauma

The increasing number of diagnostic angiograms and interventional vascular procedures has resulted in a heightened awareness of serious catheter-related vascular trauma. We reviewed 50 consecutive catheter injuries of the femoral artery that required surgical intervention and focused specifically on their long-term outcome. The most common traumatic lesion was femoral pseudoaneurysm (60%) followed by uncontrolled hemorrhage (23%) and arterial thrombosis (17%). The most frequent chronic complaint of these patients was the femoral neuralgia syndrome affecting 15 of 50 patients (30%). Typically, these patients complained of postcatheterization pain in the groin, which radiated down the anteromedial thigh (anterior femoral cutaneous nerves), and was associated with residual hyperesthesias. The neuralgia gradually improved in 6 weeks to 1 year in most patients. Chronic pain, however, necessitated multiple visits to a pain clinic or physical therapy unit in four patients (27%) and resulted in unemployment in three (20%). We conclude that current catheter-related arterial injuries are commonly associated with a chronic femoral cutaneous neuralgia syndrome that has not been emphasized previously.     

Compression of the lateral femoral cutaneous nerve by a fibrous sartorius strand in a professional female soccer player

Meralgia paraesthetica represents a neuropathy involving pain, burning, tingling, and numbness in the distribution of the lateral femoral cutaneous nerve (LFCN) of the thigh, which is commonly due to nerve entrapment under the inguinal ligament. We report an unusual case of compression of the LFCN at the anterior surface of the sartorius muscle in a professional female soccer player. Intraoperatively, the LCFN was found to pass without major compression under the inguinal ligament, but was strained over a fibrous thickening of the superficial thigh fascia and the anterior medial border of the sartorius muscle 8 cm caudal of the inguinal ligament. Excision of the fibrous tissue completely resolved the symptoms. In professional athletes, the LFCN should be explored along its entire course on the anterior thigh during operative decompression to rule out a distal muscular compression site. Level of evidence: Level V, therapeutic study     

The Influence of Anatomic Location on Functional Outcome in Lower-Extremity Soft-Tissue Sarcoma

Background: The purpose of this study was to explore the relationship between the anatomical location of lower-extremity soft-tissue sarcoma and functional outcome.Methods: Function was evaluated with the Musculoskeletal Tumor Society (MSTS 1993) score and Toronto Extremity Salvage Score (TESS); 207 patients (median age, 54 years) were eligible. The median maximum tumor diameter was 8.0 cm; 58 tumors were superficial and 149 were deep. Nine locations based on anatomical compartments were defined: 6 tumors were in the groin/femoral triangle; 8, the buttock; 52, the anterior thigh; 22, the medial thigh; 20, the posterior thigh; 10, the popliteal fossa; 13, the posterior calf; 11, the anterolateral leg; and 7, the foot or ankle.Results: Treatment of superficial tumors did not lead to significant changes in MSTS score (mean, 90.6% preoperatively vs. 93.0% postoperatively; P = .566) or TESS (mean, 86.4% preoperatively vs. 90.9% postoperatively; P = .059). Treatment of deep tumors lead to significant reductions in MSTS score and TESS (mean MSTS, 86.9% preoperatively vs. 83.0% postoperatively; P = .001; and mean TESS, 83.0% preoperatively vs. 79.4% postoperatively; P = .015). Anatomical location was not a significant predictor of aggregated MSTS and TESS evaluations. Exploratory analysis showed variation in MSTS pain and gait handicap or limp items and TESS dressing, sitting, bending, and bathing items by anatomical location.Conclusions: The treatment of superficial tumors does not lead to significant changes in MSTS score or TESS. Anatomical location is not a significant predictor of aggregated MSTS and TESS evaluations. However, there is variation in MSTS and TESS item scores across anatomical locations.