[Arthroscopic synovectomy of the hip joint]. / Arthroskopische Synovektomie des Hüftgelenks.

OBJECTIVE: The aim of the treatment is reduction of hip pain through arthroscopic synovectomy of the hip joint, reduction in activity of the synovial disease and removal of loose bodies in chondromatosis. INDICATIONS: Synovialitis of the hip due to synovial disease, such as pigmented villonodular synovitis (PVNS) and chondromatosis, synovialitis of the hip due to a further diseases of the hip. The disease must be treatable by arthroscopy (e.g. femoroacetabular impingement and lesion of the acetabular labrum). CONTRAINDICATIONS: Suspicion of malignant synovial disease, extensive synovitis, especially in those areas of the hip which are difficult to reach or inaccessible to arthroscopy, primary disease not sufficiently treatable by arthroscopy, e.g. coxarthrosis. SURGICAL TECHNIQUE: Arthroscopy of the central compartment of the hip is carried out by lateral, anterolateral (alternatively inferior anterolateral) and posterolateral portals, using all portals both for the camera and for instruments. In the central compartment synovectomy of the acetabular fossa is performed. A shaver and/or a high frequency diathermy applicator (HF applicator) are employed for removal of the synovial membrane. For arthroscopy of the peripheral compartment lateral, anterolateral (alternatively inferior anterolateral) and superior anterolateral portals are established and all portals are used both for the camera and instruments. In the peripheral compartment, the synovial membrane of the anterior, anteromedial, anterolateral and as far as possible posterolateral areas of the hip is removed. The dorsolateral synovial plica needs to be spared. POSTOPERATIVE MANAGEMENT: Non-steroidal anti-inflammatory drugs (NSAIDs) are administered as prophylaxis of heterotopic ossification for 10 days. Contraindications for NSAIDs need to be considered. Thrombosis prophylaxis with low molecular weight heparin over 5 days. Mobilization with full weight bearing. Intensive physiotherapeutic exercises for at least 6 and possibly up to 12 postoperative weeks. Radiosynoviorthesis 6-8 weeks after surgery depending of the histopathological results. RESULTS: From June 2007 to December 2013 a total of 20 patients with specific synovial diseases were treated with hip arthroscopy of which 18 had chondromatosis and 2 had PVNS. A telephone interview was carried out after an average of 40.2 months (range 8-92 months) and revealed a recurrence rate of the synovial disease of 20 %. In two cases (10 %) a second arthroscopy was necessary due to recurrent symptoms but without return of the synovial disease.

[Arthroscopic arthrolysis of the hip]. / Arthroskopische Arthrolyse des Hüftgelenks.

OBJECTIVE: Increase of range of motion and pain reduction for pain limited movement of the hip joint by arthroscopic arthrolysis of the peripheral compartment. INDICATIONS: Painful primary or secondary restriction of movement of the hip joint with adhesive capsulitis and after previous surgery or additional arthroscopically treatable intra-articular changes. CONTRAINDICATIONS: Extensive periarticular ossification, severe arthrofibrosis and advanced arthritis of the hip. SURGICAL TECHNIQUE: Arthroscopy of the peripheral compartment of the hip, initially using a lateral portal for the arthroscope and an anterolateral portal for instruments. After expansion of the portal entry site with a shaver and/or HF applicator and removal of scar tissue between the capsule and femoral neck, the capsule is reduced from anterolateral to anteromedial. After exchange of arthroscope and working portal, the lateral and dorsolateral arthrolysis is done. POSTOPERATIVE MANAGEMENT: Administration of nonsteroidal anti-inflammatory drugs for prophylaxis of heterotopic ossifications. Thrombosis prophylaxis with heparin. Mobilization with full weight bearing. Intensive physiotherapeutic exercises for at least for 6 weeks and if needed for 12 postoperative weeks. RESULTS: After arthroscopic (n=38) or open (n=11) hip surgeries, 49 revision hip arthroscopies were performed from January 2009 to August 2013. Arthrolysis in the described technique was performed if adhesions were present. In 19 of these cases, a limitation of at least 30 % for one direction of movement was present pre-operatively. The following average values were obtained for the range of motion (preoperative/postoperative/increase): flexion 94°/128°/34 °, abduction 18°/40°/22°, internal rotation of 8°/20°/12°, external rotation 18°/38°/20°.

[Screw arthrodesis of the shoulder]. / Schraubenarthrodese der Schulter.

OBJECTIVE: The aim of the procedure is arthrodesis of the shoulder by osteosynthesis of the glenohumeral and the acromiohumeral joint each with three screws, which results in preservation of scapulothoracic motion and pain relief. INDICATIONS: Traumatic brachial plexus lesions, palsy in infancy, poliomyelitis with preserved or restorable function of the elbow and the hand. Paralysis of the deltoid muscle and the rotator cuff. Nonrestorable vast defect of the rotator cuff with pseudoparalysis. Chronic infectious arthritis resistant to therapy. Unsuccessful attempts to treat glenohumeral instability. Alternative procedure to shoulder arthroplasty in young patients with omarthrosis, who perform hard physical work. CONTRAINDICATIONS: Insufficient strength of the scapular muscles (< grade 4, <75% of normal strength). Insufficient scapulothoracic passive motion. Inadequate soft tissue coverage after burns, excessive previous surgery or radiotherapy. Incomplete rehabilitation (<3 years) after neurosurgical interventions (neurolysis, nerve transplantation). Cases of resection of the proximal humerus. SURGICAL TECHNIQUE: Acampsia of the shoulder joint in 20° of abduction, 30° of anteversion, and 40° of internal rotation using three glenohumeral and three acromiohumeral spongiosa screws as a compression arthrodesis. POSTOPERATIVE MANAGEMENT: Thorax-arm-abduction splint (20° of abduction, 30° of anteversion, and 40° of internal rotation) until the week 6 postoperatively with removal for physiotherapy and personal hygiene. Assisted active and passive motion exercises for the elbow, hand, and fingers after the postoperative day 1. Weaning from the splint after the end of the week 6 postoperatively, full range of motion allowed. RESULTS: In a prospective study from January 2007 to September 2008, 4 patients with a medium age of 35.7 years underwent screw arthrodesis of the shoulder with a follow-up of 1.0 (0.6-1.5) year. Primary fusion of all arthrodesis surfaces was achieved in all patients; no revision surgery was necessary. All patients improved in shoulder function with an average range of motion of 60° abduction and 40° anteversion.