[Footballer's hip]. / Die Fußballerhüfte.

Although complaints and injuries in the knee and ankle joints are very prevalent in football, the hip has so far been given very little attention. Complaints in this area are often attributed to pathological changes in the inguinal region. However, intraarticular differential diagnoses are often not taken into consideration. This article gives an overview of possible hip pathology in footballers, as well as its diagnosis and treatment.

Bernese periacetabular osteotomy through a double approach : Simplification of a surgical technique.

OBJECTIVE: Reorientation of the acetabulum to normalize load transfer or avert femoroacetabular pincer impingement to prevent osteoarthritis of the hip. INDICATIONS: Persisting acetabular dysplasia after closure of growth plates or acetabular malrotation. CONTRAINDICATIONS: High dislocation of hip, secondary acetabulum, increased misalignment on functional X­ray, high-grade mobility restriction. Relative: degenerative changes, advanced age. SURGICAL TECHNIQUE: Bernese periacetabular osteotomy through two incisions; all bone cuts are carried out under direct vision. The osteotomies are equivalent to the classic Ganz method. In a slightly tilted forward lateral decubitus position, a posterior incision is applied for the ischium osteotomy and the caudal portion of the retroacetabular osteotomy. The pubis and ilium osteotomies are performed in a supine position through an anterior approach with subsequent reorientation and screw fixation. The rectus femoris is not dissected unless joint exposure is required. POSTOPERATIVE MANAGEMENT: Partial weight bearing with 20 kg for the first 6 weeks postoperatively, followed by stepwise transition to full loads after radiological control. RESULTS: In total, 34 patients (37 hips) were followed up for 20.4 ± 10.3 months. Tönnis osteoarthritis scale levels remained constant. The center-edge angle of Wiberg increased from 13.2 ± 7.5° to 26.5 ± 6.7°, the Tönnis angle (acetabular index) changed from 13.8 ± 6.5° to 3.4 ± 4.4°. At follow-up, the Merle d'Aubigné and Postel score was 16.5 ± 1.4; the modified Harris hip score 87.6 ± 13.9 and the International hip outcome tool (iHOT)-12 78.2 ± 20.3 points. The mean surgical time was 213 ± 29 min. Severe complications were not observed.

Arthroscopic treatment of femoroacetabular pincer impingement.

OBJECTIVE: Arthroscopic resection of the bony overhang of the acetabular rim with concurrent treatment of associated chondrolabral injury in order to improve femoroacetabular clearance, provide symptomatic relief and in theory, delay the onset or progression of osteoarthritis of the hip. INDICATIONS: Clinical and radiographic evidence of femoroacetabular pincer or combined impingement, with minimal to moderate degenerative change in the hip joint. CONTRAINDICATIONS: Advanced osteoarthritis of the hip joint. Femoroacetabular pincer impingement arising from generalised overcoverage, e.g. coxa profunda. Acetabular retroversion in a dysplastic hip. SURGICAL TECHNIQUE: Arthroscopy of the peripheral compartment, using a proximal anterolateral viewing portal and anterior and anterolateral working portals. Labral assessment, release from its capsular reflection, limited bony resection of the acetabular rim or labral ossification. Central compartment arthroscopy under traction, using the anterolateral and anterior portals alternately as viewing and working portals, and a distal anterolateral accessory portal. The labrum is detached to expose the bony overhang in the acetabular rim, which is resected with a burr. The labrum is refixed if it is of sufficient quality and debrided or resected otherwise. POSTOPERATIVE MANAGEMENT: Labral resection: partial weight bearing, with pain-controlled progression to full weight bearing over 1-2 weeks. Labral refixation: Protected (20 kg) weight bearing for the first 4 weeks. Continuous passive motion therapy and the use of a stationary bicycle for 4 weeks, and early proprioceptive training are part of the rehabilitation regimen. RESULTS: Arthroscopic treatment of femoroacetabular impingement has been shown to provide symptomatic relief, improve hip outcome scores and is postulated to delay progression of osteoarthritis. Better clinical outcomes can be obtained with labral refixation if the labrum is of sufficient quality.

[Complications after minimally invasive total hip arthroplasty]. / Komplikationen nach minimal-invasiver Hüftendoprothetik.

BACKGROUND: The goal of minimally invasive surgery in total hip arthroplasty (MIS-THA) is reduction of surgical trauma without any limitations regarding exposure of the femur and acetabulum to achieve reproducible results. Despite improved instrumentation the implementation of these techniques is associated with a risk of higher complication rates. AIM: The article describes specific and unspecific complications of MIS-THA and gives hints and tips on how to avoid them. MATERIAL AND METHODS: In a retrospective study 152 THA revisions following MIS-THA were examined and an error analysis was performed. RESULTS: The study of 152 MIS-THA revisions included 87 female and 65 male patients. A gender-specific incidence of complications could not be found. The most common indication for revision surgery was due to recurrent dislocation. An increased incidence of fractures of the greater trochanter was observed using the anterolateral approach with the patient in a supine position. DISCUSSION: The MIS-THA procedure contributes to excellent early rehabilitation when performed correctly. The muscle preserving aspect can be counted as an advantage particularly for young patients. This patient collective has a high risk to undergo revision surgery.

[Arthroscopic therapy algorithm for septic coxitis]. / Arthroskopischer Therapiealgorithmus bei septischer Koxitis.

Septic coxitis is a potentially life-threatening disease which necessitates an early diagnosis and effective treatment to ensure preservation of joint integrity and function. The hip joint is the second most frequently affected joint exceeded only by the knee. In adult patients septic coxitis has a hematogenous and iatrogenic origin in approximately 50 % of cases each (after intra-articular injection and surgery) but in children hematogenous infections are the most common. Septic arthritis of the hip leads to severe functional loss in up to 25% of patients. The treatment consists of systemic antibiotic therapy and stage-adjusted surgical procedures whereby arthroscopic treatment is a promising minimally invasive option for treatment in both children and adults.

[Arthroscopic treatment of femoroacetabular impingement. Technique and results]. / Arthroskopische Behandlung des femoroazetabulären Impingements. Technik und Ergebnisse.

Hip arthroscopy has become an effective and reliable operative technique for treating femoroacetabular impingement (FAI). This report presents the latest arthroscopic technique, including positioning, portal placement, and treatment of the femoral and acetabular deformity and secondary lesions at the chondrolabral rim complex. After a review of the literature, the results of arthroscopic versus open treatment of FAI are compared, and an algorithm is suggested for deciding between these two types of FAI treatment.

[Complications of hip arthroscopies]. / Komplikationen bei arthroskopischen Hüftoperationen.

Surgical complications of hip arthroscopies are rare in the hands of experienced hip arthroscopists. However, when performed by beginners and in more demanding situations such as marginal distraction of the head and socket and technically advanced procedures, the risk increases. This report describes possible complications which may happen during positioning and traction, portal placement, and diagnostic and therapeutic procedures. Possible causes of soft tissue lesions of the portal area, perineum and foot, intra-articular lesions of the labrum and cartilage, direct and traction-related indirect neurovascular lesions, and other rare complications are analyzed.

Influence of deposit stage and failed ESWT on the surgical results of arthroscopic treatment of calcifying tendonitis of the shoulder.

The purpose of the present study is the evaluation of a possible influence of the preoperative deposit stage, the postoperative deposit elimination and failed preoperative extracorporeal shockwave therapy on the surgical outcome of arthroscopic treatment of tendinosis calcarea. From 1997 to 2004, 65 patients underwent arthroscopic resection of calcific deposits of the shoulder after failed conservative treatment. Patients with rotator cuff tears, major cartilage damage, or previous surgery were excluded. Out of 50 patients 45 (17 men, 28 women) that could be contacted with a mean age of 49 +/- 8 years could be followed-up with a mean of 36 months (14-89) after surgery. A total of 24 patients (53.3%) underwent preoperative extracorporeal shock-wave therapy (ESWT). For the clinical evaluation the Constant and Murley Score, the Simple Shoulder Test, the Western Ontario Rotator Cuff Index (WORC) and visual analog scales for pain, function and satisfaction were used. For the radiological evaluation, the classifications according to Gaertner and Bosworth were used. Statistical analysis was done with the Wilcoxon test, the Mann-Whitney test and ANOVA. The Constant and Murley Score improved significantly from preoperative 63.5 +/- 11.4 to postoperative 93.9 +/- 9.9 points (P < .0001) at follow-up, the Simple Shoulder Test from 1.7 +/- 2 to 9.9 +/- 2.8 points (P < .0001), the WORC score from 1,591.2 +/- 337.4 to 345.4 +/- 392 points (P < .0001). The visual analog scales for pain, function and patient satisfaction also significantly improved (P < .0001). Preoperative radiological evaluation according to the Gaertner classification revealed 37 type I deposits, 6 type II and 2 type III deposits; postoperative no calcific deposits were seen in 37 patients, 6 type I and 2 type III deposits. According to the Bosworth classification 13 type I, 19 type II and 13 type III deposits were seen preoperatively. Postoperative X-rays showed 6 type I and 1 type II and III deposits. There was no significant correlation of the clinical results with the pre- or postoperative findings. The 24 patients who underwent ESWT before surgery did not show significantly better results than patients without ESWT. In conclusion, arthroscopic removal of calcific deposits of the shoulder shows good clinical results for pain reduction, shoulder function and patient satisfaction. The type of calcific deposit and the preoperative treatment of the shoulder with ESWT did not have any significant impact on the postoperative results.

[Intra-articular bupivacaine following hip joint arthroscopy. Effect on postoperative pain]. / Intraartikuläre Bupivacaingabe bei Hüftgelenkarthroskopie. Effekt auf postoperative Schmerzen.

The effect of intra-articular bupivacaine on postoperative pain following arthroscopy has been intensively studied for the knee joint but no data are currently available for the hip joint. The aim of the present prospective, randomized and double-blind study was to evaluate a possible effect of intra-articular bupivacaine on postoperative pain intensity following hip arthroscopy. A total of 26 patients were included: 13 received 20 ml of 0.25% bupivacaine through the trocar at the end of surgery and 13 patients received 20 ml of 0.9% NaCl as placebo. Postoperative pain intensity was assessed using a visual analogue scale (VAS) at 0.5 h, 4 h, 8 h, 12 h, 16 h and 20 h, at rest and during movement of the joint and on the basis of additional piritramide requirements. Furthermore, a mean VAS was calculated as the arithmetic mean of all VAS scores assessed over the whole study period. In the bupivacaine group, a significantly lower mean VAS was recorded at rest (17.5 vs 27.5, p=0.05) and during movement of the hip joint (23 vs. 46, p=0.001). The additional piritramide consumption tended to be higher in the placebo group. In conclusion, intra-articular bupivacaine following arthroscopic hip surgery reduces pain in the postoperative period mainly during movement and thus may possibly allow earlier mobilization.

[Hip arthroscopy for femoroacetabular impingement]. / Arthroskopische Behandlung des femoroazetabulären Impingements.

Femoroacetabular impingement (FAI) is likely one of the main causes for osteoarthritis in young adults. Surgical treatment has until now been performed via open dislocation of the hip joint. With respect to its invasive nature and long rehabilitation, arthroscopic techniques have become established in recent years. The following article presents the latest developments in hip arthroscopy for FAI with a detailed description of technical aspects, pitfalls, and limitations. Hip arthroscopy is performed in the standard fashion with and without traction for arthroscopy of the central and peripheral compartments. Under traction, the anterosuperior cartilage and adjacent base of the acetabular labrum have to be inspected for frequent lesions such as cartilage flap tears and delaminations of the cartilage from the subchondral bone. An ossified labrum can be trimmed back with a burr. Currently, techniques are being developed for temporary detachment of the labrum, trimming of the acetabular rim, and refixation of the labrum with suture anchors. Without traction, femoroacetabular impingement has to be confirmed arthroscopically under flexion, internal rotation, and adduction of the hip. With respect to the frequent loss of internal rotation, the zona orbicularis and the iliofemoral ligament are released and removed if needed. The anterolateral bump of the head-neck junction is trimmed back for restoration of a more physiological head-neck offset. Postoperatively, continuous passive motion is important to prevent adhesions between the bleeding bone of the head-neck junction and the articular capsule. Weight bearing as tolerated is allowed if no treatment of cartilage defects or refixation of the acetabular labrum was performed. The early results after hip arthroscopy for FAI are very promising. Arthroscopic techniques will upstage open exposures of the hip joint for the treatment of FAI.

[Synovial disorders and loose bodies in the hip joint. Arthroscopic diagnostics and treatment]. / Synoviale Erkrankungen und freie Körper des Hüftgelenks. Arthroskopische Diagnostik und Therapie.

Synovial disorders and loose bodies are one of the most common indications for hip arthroscopy. Arthroscopic intervention has been reported for loose bodies, synovial plicae, synovial chondromatosis, pigmented villonodular synovitis (PVNS) as well as rheumatoid and septic arthritis. One major advantage in comparison to radiologic imaging is the ability to inspect, biopsy, and treat within one procedure. In contrast to an arthrotomy, hip arthroscopy avoids the potential risks of extensive surgical exposure and prolonged rehabilitation. Nevertheless, hip arthroscopy cannot be promoted as curative in all synovial disorders. In patients with loose bodies, synovial plicae, initial septic arthritis and, to a certain extent, PVNS curative therapy and "restitutio ad integrum" can be achieved. In contrast, in patients with synovial chondromatosis and rheumatoid arthritis, the goal of hip arthroscopy is to enable the correct diagnosis and to provide symptomatic relief and maintain or improve joint function. Success or failure of arthroscopic treatment depends on proper patient selection and a correct arthroscopic technique.

[Hip arthroscopy. Technique for positioning and distraction]. / Hüftarthroskopie. Lagerungs- und Distraktionstechnik.

Arthroscopy of the hip joint can be performed in the supine or lateral position. The decision whether to use the supine or lateral position appears to be more a matter of individual training or habit. Both positions have specific pros and cons. The operative experience with arthroscopy of the central and peripheral compartment shows that a combined procedure with and without traction is beneficial. Whereas arthroscopy of the central compartment in normal joints of adults is feasible only with traction, the peripheral compartment can be better scoped without traction. The combination of both techniques however is technically demanding. Particularly for arthroscopy of the central compartment with traction, the success of the operative procedure is strongly correlated with a correct technique of positioning and distraction. Precise positioning and thick padding of the counterpost, secure fixation and thick padding of the foot, and the limitation of magnitude and duration of traction are important features in order to avoid soft tissue and nerve damage. Good relaxation, joint position, and distension of the joint to break the joint vacuum significantly improve distraction of the femoral head from the socket. In combination with fluoroscopy, scope trauma to the acetabular labrum and hyaline cartilage can be minimized. For arthroscopy of the peripheral compartment without traction, the counterpost is removed and the foot taken out of the traction module for free range of motion of the leg and hip joint. This allows dynamic testing of the hip and access to different parts of the peripheral labrum, proximal femur, and soft tissues.

Hip arthroscopy without traction: In vivo anatomy of the peripheral hip joint cavity.

PURPOSE: To describe the in vivo anatomy of the peripheral compartment of the hip joint using a systematic sequence of examination without traction. TYPE OF STUDY: Case series. METHODS: We performed 35 hip arthroscopies without traction from an anterolateral portal in the supine position. Free draping and a good range of movement of the hip joint were used to relax parts of the capsule and increase the intra-articular volume of the area that was inspected. Each procedure was documented on a standard protocol including detailed information on technical features and normal and pathologic intra-articular findings. RESULTS: A comprehensive inspection of the peripheral compartment was obtained from the anterolateral portal. A systematic sequence of examination was developed separating the periphery of the hip joint into 7 areas: anterior neck area, medial neck area, medial head area, anterior head area, lateral head area, lateral neck area, and posterior area. The arthroscopic in vivo anatomy of each area is described. In 3 patients, 1 to 3 loose bodies were removed. In 1 patient with a synovial chondromatosis, 40 chondromas were retrieved. In osteoarthritis, impinging osteophytes were trimmed in 3 cases and partial synovectomy was performed in 10 patients. The following complications were observed: a temporary sensory deficit of the lateral femoral cutaneus nerve in 1 patient, scuffing of the anterior surface of the femoral head in 3 patients, detaching of an osteophyte in 1 patient, and partial tears of the anterior synovial fold in 10 patients. CONCLUSIONS: Arthroscopy without traction allows for a complete evaluation of hip anatomy without the loaded articular surfaces, the acetabular fossa, and the ligamentum teres. For a complete overview of both the central and peripheral part of the hip, traction is necessary for the central part.

Fracture of the proximal tibia six months after Fulkerson osteotomy. A report of two cases.

The Fulkerson osteotomy has proved to be a reliable treatment for subluxation of the patella due to malalignment. Aggressive rehabilitation in the early postoperative period is unwise since the proximal tibia is weakened by the oblique osteotomy. Early weight-bearing and unrestricted activity have caused fractures in a few patients. Even late in the postoperative period the osteotomy may adversely influence the biomechanical properties of the proximal tibia. We describe two athletes who sustained a fracture of the proximal tibia, during recreational activities, six months after a Fulkerson osteotomy. Both had been bearing full weight for about ten weeks without complaint. Bony healing of the osteotomy had been demonstrated on plain radiographs at ten and at 12 weeks. After a Fulkerson osteotomy, jogging and activities which impose considerable impact force should be discouraged for at least nine to 12 months.

[Hip arthroscopy. Minimal invasive diagnosis and therapy of the diseased or injured hip joint]. / Hüftarthroskopie. Minimal-invasive Diagnostik und Therapie des erkrankten oder verletzten Hüftgelenks.

Arthroscopy of the hip joint has developed into a useful tool for the hip surgeon. Hip joint anatomy, however, makes special demands of the arthroscopist. He needs to be familiar with the arthroscopic anatomy of the hip and its variations. Moreover, he should have practical training in the technique of hip arthroscopy prior to his first intraoperative experience in order to avoid complications. A complete arthroscopic inspection of the hip can be achieved by using a combined procedure: whereas the central hip compartment can be scoped only by distraction of the joint, the periphery can be better seen without traction. Whether to place the patient supine or lateral is dependent on personal experience. No matter which position is used, the positioning technique has to be exact. The literature has shown that most complications are related to traction. Before the first portal is placed, the joint vacuum force should be broken by distension of air or fluid. This leads to maximum distraction of the joint and reduces the risks of damage to labrum and cartilage during first access to the joint. For a diagnostic round through the central compartment, at least two portals have to be placed. The use of a 3-portal technique increases the range of inspection. Due to the relatively thin soft tissue mantle and greater distance to neurovascular structures, the anterolateral or lateral portal should be used as the first portals to the central compartment. In addition, the anterolateral portal is the standard portal to the periphery of the hip. The posterolateral or anterior portal should be used as a supplementary portal. The following indications have been described for an arthroscopic procedure of the hip: loose bodies, labral lesions, synovial diseases such as chondromatosis and pigmented villonodular synovitis, associated lesions in underlying osteoarthritis, ruptures of the teres ligament, malorientation of the acetabulum and proximal femur and, last but not least, "idiopathic" hip pain. The use of hip arthroscopy in infectious arthritis, avascular necrosis of the femoral head, Perthes' disease, osteochondrosis dissecans and complications after total hip replacement is less frequent. Here, in addition to its diagnostic value, operative arthroscopy of the hip offers removal of loose bodies, resection of the labrum and ligaments, synovial biopsy, partial synovectomy, microfracturing, lavage and placement of intraarticular drainage. The first results of arthroscopic procedures in the hip are promising. In addition to its diagnostic value and contribution to the understanding of intraarticular anatomy and pathology, recent studies have demonstrated the advantages of the arthroscopic treatment of the hip.

Chondral lesions after arthroscopic meniscus repair using meniscus arrows.

Meniscus repair using bioabsorbable devices has become popular in the last few years. Good clinical results have been reported and few complications have been published. This report describes the case of a 37-year-old male patient with a lateral meniscus repair using 4 Meniscus Arrows (Bionx Implants, Blue Bell, PA). Postoperatively, repeated episodes of intra-articular effusions have occurred. A second-look arthroscopy 8 months after the reconstruction showed that the meniscus tear had not healed and revealed the presence of chondral damage corresponding to the location of the arrows in the posterior area of the lateral femoral condyle. Surgeons using the Meniscus Arrow should be aware of this possible postoperative complication.

[Arthroscopy for diagnosis and therapy of early osteoarthritis of the hip]. / Hüftarthroskopie bei radiologisch beginnender bis mässiggradiger Koxarthrose. Diagnostische und therapeutische Wertigkeit.

Failure to conservative treatment in patients with less advanced radiographic signs of osteoarthritis of the hip (Danielsson grade 2-5) confronts with the decision of further treatment. Since radiographic imaging has not been proved very useful in demonstrating intraarticular structures and results of hip arthroscopies have been promising, arthroscopies have been performed in 17 hips from November 1997 to September 1998. Arthroscopic findings were exceeding preoperative imaging. In addition to cartilage degeneration, concomitant loose bodies, impinging osteophytes, degeneration of the labrum and synovial disease were found. Removal of loose bodies and osteophytes, partial resection of labral tears and partial synovectomy were performed. 1 month after arthroscopy (n = 15), mean Harris-Hip-Score was increased by 13 points und pain reduced by 39 % on average. 6 months after arthroscopy (n = 9), mean Harris-Hip-Score was increased by 14 points and pain reduced by 32 % on average. In addition to its therapeutic benefit, arthroscopy offers direct visualisation of the hip providing important information for the decision of further treatment.

Unilateral osseous bridging between the arches of atlas and axis after trauma.

STUDY DESIGN: This is a case report. OBJECTIVE: To present a case of osseous bridging between C1 and C2 of posttraumatic origin and with an associated closed head injury and to discuss its pathogenesis and clinical outcome after surgical resection. SUMMARY OF BACKGROUND DATA: Heterotopic ossifications of posttraumatic origin in the spine are rare. To the authors' knowledge, no cases have been reported of spontaneous bony bridging between C1 and C2 with a posttraumatic origin. METHODS: Heterotopic ossifications were detected when pain and limited axial rotation (left/right 10 degrees/0 degree/20 degrees) were persistent, despite intensive physical therapy. Because heterotopic ossifications were ankylosing C1 and C2, the decision was to resect the osseous bridge in combination with a careful mobilization of the cervical spine. Functional computed tomography was performed for analysis of the postoperative results. RESULTS: Four months after surgery, clinical examination showed asymptomatic increased axial rotation. Functional computed tomography indicated that left C1-C2 axial rotation was reduced, possibly related to impingement caused by residual bony spurs. Pathologic changes in the surrounding soft tissue may be another important factor in the persistent limitation of rotation. CONCLUSIONS: Osseous bridging between C1 and C2 may be considered when persistent pain and limited axial rotation are observed after trauma. Operative resection, together with careful intraoperative and postoperative mobilization, may be the treatment of choice.