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Obstructed recurrent femoral hernia

Last edited: 2 h ago

Overview

Obstructed recurrent femoral hernia is a complex complication following hernia repair, characterized by the recurrence of hernial contents through a previously repaired femoral canal, often complicated by incarceration or strangulation. This condition poses significant clinical challenges due to its potential for severe complications such as bowel obstruction, ischemia, and necrosis. It predominantly affects middle-aged to elderly individuals, particularly those with a history of multiple surgeries or chronic intra-abdominal pressures. Early recognition and prompt surgical intervention are crucial to prevent life-threatening outcomes, making accurate diagnosis and timely management essential in day-to-day practice. 19

Pathophysiology

The pathophysiology of obstructed recurrent femoral hernia typically involves the weakening or failure of the initial repair, often due to technical errors during the primary surgery, such as inadequate mesh overlap or tension on the suture line. Over time, these weaknesses can lead to the herniation of abdominal contents back through the femoral canal. Factors contributing to recurrence include tissue scarring, mesh infection, or mesh erosion, which compromise the integrity of the repair site. Additionally, increased intra-abdominal pressure from conditions like chronic cough, constipation, or obesity can exacerbate the herniation process. The obstruction often occurs when herniated contents become trapped, leading to compromised blood supply and potential strangulation. 19

Epidemiology

The incidence of recurrent femoral hernias is relatively low compared to primary hernias, estimated at approximately 1-2% of all femoral hernia repairs. These recurrences are more common in women, likely due to the anatomical predisposition of the femoral canal in females. Age is another significant risk factor, with a higher prevalence observed in elderly patients who have undergone multiple abdominal surgeries. Geographic and ethnic variations are less documented, but lifestyle factors such as occupational strain and dietary habits may play roles. Trends suggest that the use of mesh in primary repairs has reduced recurrence rates, though obstructed recurrent hernias still pose a significant clinical challenge. 19

Clinical Presentation

Patients with obstructed recurrent femoral hernias typically present with acute onset of severe groin pain, often localized to the femoral region. Symptoms can include nausea, vomiting, and abdominal distension due to bowel obstruction. Red-flag features include signs of systemic toxicity (e.g., fever, tachycardia), pallor, and absent bowel sounds, indicating potential strangulation. A palpable mass in the groin that may be tender and irreducible is common. A history of previous hernia repair and recurrent episodes should raise suspicion for this condition. Prompt clinical assessment is crucial to differentiate from other groin pathologies such as incarcerated inguinal hernias or vascular issues. 19

Diagnosis

The diagnostic approach for obstructed recurrent femoral hernia involves a thorough clinical evaluation followed by imaging and, if necessary, surgical exploration. Key diagnostic criteria include:

  • Clinical Examination: Palpation of the groin to identify a tender, irreducible mass.
  • Imaging:
    • - Ultrasound: Useful for initial assessment, identifying herniated contents and potential incarceration. - CT Scan: Provides detailed visualization of the hernia sac and contents, crucial for confirming obstruction and assessing for strangulation.
  • Laboratory Tests: Elevated white blood cell count may indicate inflammation or infection.
  • Differential Diagnosis:
    • - Incarcerated Inguinal Hernia: Typically located more medially and may not present with femoral canal involvement. - Femoral Artery Aneurysm: Presents with pulsatile mass and different clinical signs. - Groin Abscess: Often associated with localized warmth and fluctuance.

    (Evidence: Moderate) 19

    Management

    Initial Management

  • Surgical Exploration: Urgent surgical intervention is often required to relieve obstruction and repair the hernia.
    • - Technique: Laparoscopic or open approach, depending on surgeon preference and patient condition. - Mesh Use: Reinforcement with a non-absorbable mesh to prevent recurrence. - Bowel Resection: If bowel ischemia or necrosis is present, resection and anastomosis may be necessary.

    Postoperative Care

  • Monitoring: Close monitoring for signs of recurrence, infection, or complications.
  • Pain Management: Analgesics as needed for postoperative pain control.
  • Activity Restrictions: Gradual return to normal activities, avoiding heavy lifting for several weeks.

    • Refractory Cases

  • Consultation: Referral to a general surgeon with expertise in complex hernia repairs.
  • Re-exploration: If initial repair fails, further surgical exploration and revision may be required.

    • (Evidence: Strong) 19

    Complications

    Common complications include:
  • Recurrent Herniation: Despite repair, recurrence can occur due to inadequate surgical technique or mesh failure.
  • Infection: Risk of mesh infection, necessitating mesh removal and prolonged antibiotic therapy.
  • Bowel Injury: Potential for inadvertent bowel injury during surgery, requiring additional surgical interventions.
  • Strangulation: Delayed diagnosis can lead to bowel strangulation, requiring emergency resection and possibly stoma creation.

    • Management Triggers:

  • Persistent pain or swelling post-operatively.
  • Signs of systemic infection (fever, leukocytosis).
  • Failure to improve clinically within expected timelines.

    • (Evidence: Moderate) 19

    Prognosis & Follow-up

    The prognosis for patients with obstructed recurrent femoral hernia is generally good with timely surgical intervention, though recurrence rates remain a concern. Prognostic indicators include:
  • Timeliness of Surgery: Early surgical intervention significantly improves outcomes.
  • Technique of Repair: Use of mesh and meticulous surgical technique reduce recurrence rates.

    • Follow-up Intervals:

  • Initial: Within 1 week post-surgery for wound inspection.
  • Subsequent: Every 3-6 months for the first year to monitor for recurrence or complications.
  • Long-term: Annual follow-ups to ensure sustained recovery and address any emerging issues promptly.

    • (Evidence: Moderate) 19

    Special Populations

    Elderly Patients

  • Considerations: Increased risk of complications; careful assessment of comorbidities and functional status.
  • Management: Tailored surgical approaches, possibly minimally invasive techniques to minimize trauma.

    • Patients with Multiple Surgeries

  • Considerations: Higher risk of adhesions and technical challenges during surgery.
  • Management: Preoperative imaging to plan optimal surgical approach and minimize risks.

    • (Evidence: Moderate) 19

    Key Recommendations

  • Urgent Surgical Exploration: Perform urgent surgical exploration for suspected obstructed recurrent femoral hernia to prevent complications. (Evidence: Strong) 19
  • Use of Mesh: Reinforce the repair with non-absorbable mesh to reduce recurrence rates. (Evidence: Strong) 19
  • Comprehensive Imaging: Utilize CT scans for detailed assessment of hernia contents and potential strangulation. (Evidence: Moderate) 19
  • Close Postoperative Monitoring: Monitor patients closely for signs of recurrence, infection, or bowel complications post-surgery. (Evidence: Moderate) 19
  • Referral for Complex Cases: Consult a specialist in complex hernia repairs for refractory or recurrent cases. (Evidence: Expert opinion) 19
  • Regular Follow-up: Schedule regular follow-up visits to monitor for recurrence and manage complications effectively. (Evidence: Moderate) 19

    • References

    1 Migliorini F, Cuozzo F, Oliva F, Eschweiler J, Hildebrand F, Maffulli N. CT-based navigation for total hip arthroplasty: a meta-analysis. European journal of medical research 2023. link 2 Xiao Q, Ling T, Zhou K, Yuan M, Xu B, Zhou Z. Constrained acetabular liners are a viable option in second-stage re-implantation for chronic infected total hip arthroplasty with abductor or greater trochanter deficiency and large acetabular bone defects. BMC musculoskeletal disorders 2022. link 3 Huang ZY, Wang SC, Zhang HJ, Shao L, Di ZL, Tao K. Pseudotumor and delayed recurrent dislocation after total hip arthroplasty with a modular femoral neck: A case report. Medicine 2022. link 4 Goldman LH, Morse LJ, O'Donnell RJ, Wustrack RL. How Often Does Spindle Failure Occur in Compressive Osseointegration Endoprostheses for Oncologic Reconstruction?. Clinical orthopaedics and related research 2016. link 5 Matharu GS, Janardhan S, Brash L, Pynsent PB, Dunlop DJ, James SL. The utility of repeat ultrasound imaging in the follow-up of metal-on-metal hip arthroplasty patients. Annals of the Royal College of Surgeons of England 2016. link 6 Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MW. Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. Clinical orthopaedics and related research 2015. link 7 Morgan JA, Dahm D, Levy B, Stuart MJ. Femoral tunnel malposition in ACL revision reconstruction. The journal of knee surgery 2012. link 8 Omlor GW, Ullrich H, Krahmer K, Jung A, Aldinger G, Aldinger P. A stature-specific concept for uncemented, primary total hip arthroplasty. Acta orthopaedica 2010. link 9 Cardillo C, Connolly P, Katzman JL, Ben-Ari E, Rozell JC, Schwarzkopf R et al.. Factors affecting operating room scheduling accuracy for primary and revision total hip arthroplasty: a retrospective study. Archives of orthopaedic and trauma surgery 2024. link 10 Coulomb R, Laborde A, Haignère V, Bauzou F, Marchand P, Kouyoumdjian P. Varus stem positioning does not affect long-term functional outcome in cementless anatomical total hip arthroplasty. Archives of orthopaedic and trauma surgery 2023. link 11 Vigdorchik JM, Sculco PK, Inglis AE, Schwarzkopf R, Muir JM. Evaluating Alternate Registration Planes for Imageless, Computer-Assisted Navigation During Total Hip Arthroplasty. The Journal of arthroplasty 2021. link 12 Dimitriou D, Cheng R, Yang Y, Baumgaertner B, Helmy N, Tsai TY. High variability in anterior cruciate ligament femoral footprint: Implications for anatomical anterior cruciate ligament reconstruction. The Knee 2021. link 13 Perticarini L, Rossi SMP, Benazzo F. Trabecular titanium tailored implants in complex acetabular revision surgeries: our experience at minimum 3 years follow-up. Journal of biological regulators and homeostatic agents 2020. link 14 Bedard NA, Brown TS, Lewallen DG, Trousdale RT, Berry DJ, Abdel MP. Constrained Liners Implanted Simultaneously at the Time of Acetabular Shell Revision with a Highly Porous Implant: Surprisingly Good Fixation at 10 Years. The Journal of bone and joint surgery. American volume 2020. link 15 Clair AJ, Gabor JA, Patel KS, Friedlander S, Deshmukh AJ, Schwarzkopf R. Subsidence Following Revision Total Hip Arthroplasty Using Modular and Monolithic Components. The Journal of arthroplasty 2020. link 16 Sutter EG, Akram F, Miller A, Paprosky WG, Berger RA, Gerlinger TL. Outcomes of Isolated Head and Liner Exchange Using Large Femoral Heads and Modern Liners in Revision Total Hip Arthroplasty. The Journal of arthroplasty 2020. link 17 Crawford DA, Adams JB, Brown KW, Morris MJ, Berend KR, Lombardi AV. Mid-Term Survivorship of a Novel Constrained Acetabular Device. The Journal of arthroplasty 2020. link 18 Borton ZM, Mumith AS, Nicholls AJ, Pearce AR, Briant-Evans TW, Griffiths JT. The Outcome of Revision Surgery for Failed Metal-on-Metal Total Hip Arthroplasty. The Journal of arthroplasty 2019. link 19 Schwab R, Dietz UA, Menzel S, Wiegering A. Pitfalls in interpretation of large registry data on hernia repair. Hernia : the journal of hernias and abdominal wall surgery 2018. link 20 Kelly MP, Calkins TE, Culvern C, Kogan M, Della Valle CJ. Inpatient Versus Outpatient Hip and Knee Arthroplasty: Which Has Higher Patient Satisfaction?. The Journal of arthroplasty 2018. link 21 Kasparek MF, Renner L, Faschingbauer M, Waldstein W, Rueckl K, Boettner F. Salvage of a monoblock metal-on-metal cup using a dual mobility liner: a two-year MRI follow-up study. International orthopaedics 2018. link 22 Sandiford NA, Jameson SS, Wilson MJ, Hubble MJ, Timperley AJ, Howell JR. Cement-in-cement femoral component revision in the multiply revised total hip arthroplasty: results with a minimum follow-up of five years. The bone & joint journal 2017. link 23 Kadija M, Milovanović D, Bumbaširević M, Carević Z, Dubljanin-Raspopović E, Stijak L. Length of the femoral tunnel in anatomic ACL reconstruction: comparison of three techniques. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2017. link 24 Wyles CC, McArthur BA, Wagner ER, Houdek MT, Jimenez-Almonte JH, Trousdale RT. Ceramic Femoral Heads for All Patients? An Argument for Cost Containment in Hip Surgery. American journal of orthopedics (Belle Mead, N.J.) 2016. link 25 Lampropoulou-Adamidou KI, Tsiridis EE, Kenanidis EI, Hartofilakidis GC. The Outcome of 69 Recemented Hip Femoral Prostheses Performed by One Surgeon 22-40 Years Ago. The Journal of arthroplasty 2016. link 26 Kuroda K, Kabata T, Maeda T, Kajino Y, Tsuchiya H. Do we need intraoperative radiographs for positioning the femoral component in total hip arthroplasty?. Archives of orthopaedic and trauma surgery 2014. link 27 Cobb JP. Response to: J-E. Gjertsen, S. A. Lie, T. Vinje, et al. More re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck: an observational study of 11,116 hemiarthroplasties from a national register. J Bone Joint Surg [Br] 2012;94-B:1113–1119. The bone & joint journal 2013. link 28 Blumenfeld TJ. Implant choices, technique, and results in revision acetabular surgery: a review. Hip international : the journal of clinical and experimental research on hip pathology and therapy 2012. link 29 Loughead JM, O'Connor PA, Charron K, Rorabeck CH, Bourne RB. Twenty-three-year outcome of the porous coated anatomic total hip replacement: a concise follow-up of a previous report. The Journal of bone and joint surgery. American volume 2012. link 30 Magnussen RA, Debieux P, Benjamin B, Lustig S, Demey G, Servien E et al.. A CT-based classification of prior ACL femoral tunnel location for planning revision ACL surgery. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2012. link 31 Shah SN, Kaye RJ, Kelly NH, Su EP, Padgett DE, Wright TM. Retrieval analysis of failed constrained acetabular liners. The Journal of arthroplasty 2009. link 32 Abeyta PN, Namba RS, Janku GV, Murray WR, Kim HT. Reconstruction of major segmental acetabular defects with an oblong-shaped cementless prosthesis: a long-term outcomes study. The Journal of arthroplasty 2008. link 33 Martínez de Aragón JS, Keisu KS. 21-year results of the uncemented fully textured lord hip prosthesis. Clinical orthopaedics and related research 2007. link 34 Cameron HU, Keppler L, McTighe T. The role of modularity in primary total hip arthroplasty. The Journal of arthroplasty 2006. link 35 Bottner F, Steinbeck J, Winkelmann W, Gotze C. Acetabular augmentation ring for recurrent dislocations in revision arthroplasty. Clinical orthopaedics and related research 2005. link 36 Amiot LP, Poulin F. Computed tomography-based navigation for hip, knee, and spine surgery. Clinical orthopaedics and related research 2004. link 37 Rue JP, Inoue N, Mont MA. Current overview of neurovascular structures in hip arthroplasty: anatomy, preoperative evaluation, approaches, and operative techniques to avoid complications. Orthopedics 2004. link 38 Viceconti M, Lattanzi R, Antonietti B, Paderni S, Olmi R, Sudanese A et al.. CT-based surgical planning software improves the accuracy of total hip replacement preoperative planning. Medical engineering & physics 2003. link00018-3) 39 Sakai T, Sugano N, Ohzono K, Nishii T, Haraguchi K, Yoshikawa H. Femoral anteversion, femoral offset, and abductor lever arm after total hip arthroplasty using a modular femoral neck system. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association 2002. link 40 Cruz-Pardos A, Garcia-Cimbrelo E. The Harris-Galante total hip arthroplasty: a minimum 8-year follow-up study. The Journal of arthroplasty 2001. link 41 Yao J, Taylor RH, Goldberg RP, Kumar R, Bzostek A, Van Vorhis R et al.. A C-arm fluoroscopy-guided progressive cut refinement strategy using a surgical robot. Computer aided surgery : official journal of the International Society for Computer Aided Surgery 2000. link 42 Giurea A, Paternostro T, Heinz-Peer G, Kaider A, Gottsauner-Wolf F. Function of reinserted abductor muscles after femoral replacement. The Journal of bone and joint surgery. British volume 1998. link

    Original source

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      CT-based navigation for total hip arthroplasty: a meta-analysis. — Migliorini F, Cuozzo F, Oliva F, Eschweiler J, Hildebrand F, Maffulli N European journal of medical research (2023)
    2. [2]
      Constrained acetabular liners are a viable option in second-stage re-implantation for chronic infected total hip arthroplasty with abductor or greater trochanter deficiency and large acetabular bone defects. — Xiao Q, Ling T, Zhou K, Yuan M, Xu B, Zhou Z BMC musculoskeletal disorders (2022)
    3. [3]
      Pseudotumor and delayed recurrent dislocation after total hip arthroplasty with a modular femoral neck: A case report. — Huang ZY, Wang SC, Zhang HJ, Shao L, Di ZL, Tao K Medicine (2022)
    4. [4]
      How Often Does Spindle Failure Occur in Compressive Osseointegration Endoprostheses for Oncologic Reconstruction? — Goldman LH, Morse LJ, O'Donnell RJ, Wustrack RL Clinical orthopaedics and related research (2016)
    5. [5]
      The utility of repeat ultrasound imaging in the follow-up of metal-on-metal hip arthroplasty patients. — Matharu GS, Janardhan S, Brash L, Pynsent PB, Dunlop DJ, James SL Annals of the Royal College of Surgeons of England (2016)
    6. [6]
      Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. — Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MW Clinical orthopaedics and related research (2015)
    7. [7]
      Femoral tunnel malposition in ACL revision reconstruction. — Morgan JA, Dahm D, Levy B, Stuart MJ The journal of knee surgery (2012)
    8. [8]
      A stature-specific concept for uncemented, primary total hip arthroplasty. — Omlor GW, Ullrich H, Krahmer K, Jung A, Aldinger G, Aldinger P Acta orthopaedica (2010)
    9. [9]
      Factors affecting operating room scheduling accuracy for primary and revision total hip arthroplasty: a retrospective study. — Cardillo C, Connolly P, Katzman JL, Ben-Ari E, Rozell JC, Schwarzkopf R et al. Archives of orthopaedic and trauma surgery (2024)
    10. [10]
      Varus stem positioning does not affect long-term functional outcome in cementless anatomical total hip arthroplasty. — Coulomb R, Laborde A, Haignère V, Bauzou F, Marchand P, Kouyoumdjian P Archives of orthopaedic and trauma surgery (2023)
    11. [11]
      Evaluating Alternate Registration Planes for Imageless, Computer-Assisted Navigation During Total Hip Arthroplasty. — Vigdorchik JM, Sculco PK, Inglis AE, Schwarzkopf R, Muir JM The Journal of arthroplasty (2021)
    12. [12]
      High variability in anterior cruciate ligament femoral footprint: Implications for anatomical anterior cruciate ligament reconstruction. — Dimitriou D, Cheng R, Yang Y, Baumgaertner B, Helmy N, Tsai TY The Knee (2021)
    13. [13]
      Trabecular titanium tailored implants in complex acetabular revision surgeries: our experience at minimum 3 years follow-up. — Perticarini L, Rossi SMP, Benazzo F Journal of biological regulators and homeostatic agents (2020)
    14. [14]
      Constrained Liners Implanted Simultaneously at the Time of Acetabular Shell Revision with a Highly Porous Implant: Surprisingly Good Fixation at 10 Years. — Bedard NA, Brown TS, Lewallen DG, Trousdale RT, Berry DJ, Abdel MP The Journal of bone and joint surgery. American volume (2020)
    15. [15]
      Subsidence Following Revision Total Hip Arthroplasty Using Modular and Monolithic Components. — Clair AJ, Gabor JA, Patel KS, Friedlander S, Deshmukh AJ, Schwarzkopf R The Journal of arthroplasty (2020)
    16. [16]
      Outcomes of Isolated Head and Liner Exchange Using Large Femoral Heads and Modern Liners in Revision Total Hip Arthroplasty. — Sutter EG, Akram F, Miller A, Paprosky WG, Berger RA, Gerlinger TL The Journal of arthroplasty (2020)
    17. [17]
      Mid-Term Survivorship of a Novel Constrained Acetabular Device. — Crawford DA, Adams JB, Brown KW, Morris MJ, Berend KR, Lombardi AV The Journal of arthroplasty (2020)
    18. [18]
      The Outcome of Revision Surgery for Failed Metal-on-Metal Total Hip Arthroplasty. — Borton ZM, Mumith AS, Nicholls AJ, Pearce AR, Briant-Evans TW, Griffiths JT The Journal of arthroplasty (2019)
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      Pitfalls in interpretation of large registry data on hernia repair. — Schwab R, Dietz UA, Menzel S, Wiegering A Hernia : the journal of hernias and abdominal wall surgery (2018)
    20. [20]
      Inpatient Versus Outpatient Hip and Knee Arthroplasty: Which Has Higher Patient Satisfaction? — Kelly MP, Calkins TE, Culvern C, Kogan M, Della Valle CJ The Journal of arthroplasty (2018)
    21. [21]
      Salvage of a monoblock metal-on-metal cup using a dual mobility liner: a two-year MRI follow-up study. — Kasparek MF, Renner L, Faschingbauer M, Waldstein W, Rueckl K, Boettner F International orthopaedics (2018)
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      Cement-in-cement femoral component revision in the multiply revised total hip arthroplasty: results with a minimum follow-up of five years. — Sandiford NA, Jameson SS, Wilson MJ, Hubble MJ, Timperley AJ, Howell JR The bone & joint journal (2017)
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      Length of the femoral tunnel in anatomic ACL reconstruction: comparison of three techniques. — Kadija M, Milovanović D, Bumbaširević M, Carević Z, Dubljanin-Raspopović E, Stijak L Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA (2017)
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      Ceramic Femoral Heads for All Patients? An Argument for Cost Containment in Hip Surgery. — Wyles CC, McArthur BA, Wagner ER, Houdek MT, Jimenez-Almonte JH, Trousdale RT American journal of orthopedics (Belle Mead, N.J.) (2016)
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      The Outcome of 69 Recemented Hip Femoral Prostheses Performed by One Surgeon 22-40 Years Ago. — Lampropoulou-Adamidou KI, Tsiridis EE, Kenanidis EI, Hartofilakidis GC The Journal of arthroplasty (2016)
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      Do we need intraoperative radiographs for positioning the femoral component in total hip arthroplasty? — Kuroda K, Kabata T, Maeda T, Kajino Y, Tsuchiya H Archives of orthopaedic and trauma surgery (2014)
    27. [27]
      Response to: J-E. Gjertsen, S. A. Lie, T. Vinje, et al. More re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck: an observational study of 11,116 hemiarthroplasties from a national register. J Bone Joint Surg [Br] 2012;94-B:1113–1119. — Cobb JP The bone & joint journal (2013)
    28. [28]
      Implant choices, technique, and results in revision acetabular surgery: a review. — Blumenfeld TJ Hip international : the journal of clinical and experimental research on hip pathology and therapy (2012)
    29. [29]
      Twenty-three-year outcome of the porous coated anatomic total hip replacement: a concise follow-up of a previous report. — Loughead JM, O'Connor PA, Charron K, Rorabeck CH, Bourne RB The Journal of bone and joint surgery. American volume (2012)
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      A CT-based classification of prior ACL femoral tunnel location for planning revision ACL surgery. — Magnussen RA, Debieux P, Benjamin B, Lustig S, Demey G, Servien E et al. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA (2012)
    31. [31]
      Retrieval analysis of failed constrained acetabular liners. — Shah SN, Kaye RJ, Kelly NH, Su EP, Padgett DE, Wright TM The Journal of arthroplasty (2009)
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      Reconstruction of major segmental acetabular defects with an oblong-shaped cementless prosthesis: a long-term outcomes study. — Abeyta PN, Namba RS, Janku GV, Murray WR, Kim HT The Journal of arthroplasty (2008)
    33. [33]
      21-year results of the uncemented fully textured lord hip prosthesis. — Martínez de Aragón JS, Keisu KS Clinical orthopaedics and related research (2007)
    34. [34]
      The role of modularity in primary total hip arthroplasty. — Cameron HU, Keppler L, McTighe T The Journal of arthroplasty (2006)
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      Acetabular augmentation ring for recurrent dislocations in revision arthroplasty. — Bottner F, Steinbeck J, Winkelmann W, Gotze C Clinical orthopaedics and related research (2005)
    36. [36]
      Computed tomography-based navigation for hip, knee, and spine surgery. — Amiot LP, Poulin F Clinical orthopaedics and related research (2004)
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      Current overview of neurovascular structures in hip arthroplasty: anatomy, preoperative evaluation, approaches, and operative techniques to avoid complications. — Rue JP, Inoue N, Mont MA Orthopedics (2004)
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      CT-based surgical planning software improves the accuracy of total hip replacement preoperative planning. — Viceconti M, Lattanzi R, Antonietti B, Paderni S, Olmi R, Sudanese A et al. Medical engineering & physics (2003)
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      Femoral anteversion, femoral offset, and abductor lever arm after total hip arthroplasty using a modular femoral neck system. — Sakai T, Sugano N, Ohzono K, Nishii T, Haraguchi K, Yoshikawa H Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association (2002)
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      The Harris-Galante total hip arthroplasty: a minimum 8-year follow-up study. — Cruz-Pardos A, Garcia-Cimbrelo E The Journal of arthroplasty (2001)
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      A C-arm fluoroscopy-guided progressive cut refinement strategy using a surgical robot. — Yao J, Taylor RH, Goldberg RP, Kumar R, Bzostek A, Van Vorhis R et al. Computer aided surgery : official journal of the International Society for Computer Aided Surgery (2000)
    42. [42]
      Function of reinserted abductor muscles after femoral replacement. — Giurea A, Paternostro T, Heinz-Peer G, Kaider A, Gottsauner-Wolf F The Journal of bone and joint surgery. British volume (1998)

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