Save the subchondral bone plate: Debridement versus bone marrow stimulation in acetabular cartilage defects over 60 months of follow-up.

PURPOSE: Bone marrow stimulation is a common treatment for full-thickness cartilage defects in the hip joint. However, common procedures may result in poor fibrous repair tissue and changes to the subchondral anatomy. This study investigated the clinical outcome of a cohort of International Cartilage Repair Society (ICRS) grades 3 and 4 cartilage defects treated with bone marrow stimulation compared to those who received simple debridement/chondroplasty. METHODS: In this retrospective registry study, 236 patients with uni-focal acetabular chondral lesions of the hip up to 400 mm² (mean 177.4 ± 113.4 mm²) and of ICRS grade ≥3 with follow-up of at least 12 months (mean 33.2 ± 15.3 months) were included. Eighty-one patients underwent bone marrow stimulation (microfracture: n = 44, abrasion: n = 37) besides treatment of the underlying pathology, 155 patients underwent defect debridement/chondroplasty. The patient-reported outcome was measured using the International Hip Outcome Tool 33 (iHOT33) score and the Visual Analogue Scale (VAS) for pain. RESULTS: iHOT33 and VAS both improved highly statistically significantly (p < 0.001) in the debridement group after 6, 12, 24, 36 and 60 months compared to the preoperative scores, whereas iHOT33 and VAS after microfracture or abrasion did not show statistically significant changes over time. Twenty-four and sixty months postsurgery the debridement group revealed significant higher scores in the iHOT33 compared to the bone marrow stimulation groups. CONCLUSION: Patients with chondral lesions of the hip ≤400 mm2 sustainably benefit from arthroscopic debridement under preservation of the subchondral bone plate in terms of functional outcome and pain in contrast to patients treated with bone marrow stimulation. These findings discourage the currently recommended use of microfracture in the hip joint. LEVEL OF EVIDENCE: Level III.

Patients with Small Acetabular Cartilage Defects Caused by Femoroacetabular Impingement Do Not Benefit from Microfracture.

OBJECTIVE: According to current recommendations, large cartilage defects of the hip over 2 cm2 are suggested to undergo autologous chondrocyte transplantation (ACT), while small defects should be treated with microfracture. We investigated if patients with small chondral defects of the hip joint (≤100 mm2) actually benefit from microfracture. DESIGN: In this retrospective multicenter cohort study 40 patients with focal acetabular cartilage defects smaller than 100 mm2 and of ICRS grade ≥2 caused by femoroacetabular impingement were included. Twenty-six unrandomized patients underwent microfracture besides treatment of the underlying pathology; in 14 patients cartilage lesions were left untreated during arthroscopy. Over a mean follow-up of 28.8 months patient-reported outcome was determined using the iHOT33 (international hip outcome tool) and the VAS (visual analog scale) for pain. RESULTS: The untreated group showed a statistically significant improvement of the iHOT33 after 12 (p = 0.005), 24 (p = 0.019), and 36 months (p = 0.002) compared to the preoperative score, whereas iHOT33 in the microfracture group did not reveal statistically significant changes over time. There was no significant difference between both groups on any time point. Regarding pain both groups did not show a significant improvement over time in the VAS. CONCLUSION: The subjective outcome of patients with small cartilage defects of the hip (≤100 mm2) improves 12 months after arthroscopic FAIS surgery without any cartilage treatment. However, no improvement could be seen after microfracture. Therefore, a reserved surgical treatment for small cartilage defects of the hip under preservation of the subchondral bone is recommended especially if a simultaneous impingement correction is performed.

Vascular obstruction at the level of the ankle joint as a complication of hip arthroscopy.

We report a case of foot vascular obstruction as a complication of hip arthroscopy. A 23-year-old female patient underwent hip arthroscopy for femoroacetabular impingement. The duration of the procedure was 80 minutes, including 20 minutes with traction for arthroscopy of the central compartment and 60 minutes without traction for cam treatment in the peripheral compartment. Three days postoperatively, the patient complained of a cold foot and pain and paresthesia during leg and foot elevation with continuous passive motion therapy. With persisting symptoms, she was seen by the referring physician 4 days postoperatively. Pulselessness at the level of the ankle and reduced capillary perfusion were observed. Doppler sonography and magnetic resonance angiography showed an occlusion of the peroneal, posterior tibial, and anterior tibial arteries at the level of the right ankle. The patient was readmitted to the hospital and underwent intravenous prostaglandin E1 therapy for 9 days, followed by oral clopidogrel treatment for 6 weeks. After 8 weeks, follow-up Doppler sonographic findings were normal. Subjective paresthesia and sensation of coldness resolved completely after 6 months. Possible theories for this complication and strategies on how to avoid it are discussed.

[Arthroscopic resection of the cam deformity of femoroacetabular impingement]. / Arthroskopische Behandlung des femoroazetabulären Cam-Impingements der Hüfte.

OBJECTIVE: Resection of the cam deformity of the femoral head-neck junction in order to avoid femoroacetabular impingement and the development of secondary damage to the anterolateral acetabular rim. INDICATIONS: Femoroacetabular cam impingement. Initial femoroacetabular pincer impingement. Advanced femoroacetabular pincer impingement with degenerative tear of the labrum. CONTRAINDICATIONS: Femoroacetabular pincer impingement with significant retroversion and intact acetabular labrum, coxa profunda or circumferential ossification of the labrum. Advanced osteoarthritis. SURGICAL TECHNIQUE: Arthroscopy of the peripheral compartment via three portals with and without traction. The proximal anterolateral portal is used for the arthroscope, instrumentation is done via the anterior and classic anterolateral portal. After resection of the zona orbicularis and the inner parts of the iliofemoral ligament, the anterolateral cam deformity is resected without traction via the anterior portal. After distraction of the head from the acetabulum, the lateral and posterolateral cam deformity is trimmed via the classic anterolateral portal. POSTOPERATIVE MANAGEMENT: Pain-controlled progression to full weight bearing over 1-4 weeks, continuous passive motion therapy and stationary bike for 6 weeks in order to avoid intraarticular adhesions. RESULTS: From 2004 through early 2007, 72 hip arthroscopies were performed for femoroacetabular impingement. So far, 48 patients (25 men, 23 women, mean age 37 years [17-65 years]) were followed up. After a mean follow-up of 18 months, the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) was significantly improved from 65 +/- 21 to 82 +/- 18 and the NAHS (Non Arthritic Hip Score) from 57 +/- 19 to 78 +/- 19. COMPLICATIONS: two persistent branch lesions of the lateral femoral cutaneous nerve. One patient was surgically dislocated after 8 months for the treatment of a significant retroversion of the acetabulum; one patient underwent total hip arthroplasty after 1 year.

Comparison of bioresorbable and titanium plates in cervical spinal fusion: early radiologic and clinical results.

STUDY DESIGN: This is a prospective, randomized, and controlled study, approved by the local ethical committee of Saarland (Germany), no. 209/06. OBJECTIVE: The aim of this study was to compare clinical results, segmental motility, magnetic resonance imaging (MRI) compatibility, and change of the bone density of a cervical spine segment that was treated with either bioresorbable or titanium plates in single level. SUMMARY AND BACKGROUND DATA: Anterior cervical discectomy and fusion including plate fixation is an accepted technique for treatment of symptomatic degenerative disc disease. Titanium plates have been used but cause imaging artifacts. Radiolucent bioresorbable plates and screws were developed to reduce the imaging artifacts associated with titanium. METHODS: Forty patients with single level cervical radiculopathy were randomized to anterior discectomy and fusion with bioresorbable plate (19 patients, study group) or titanium plate (18 patients, control group). Follow-up used a visual analog scale (VAS) with regard to brachial pain and Neck Disability Index (NDI) for neck pain. Radiostereometry was performed immediately postoperative and after 6 weeks, 3, and 6 months. MRI of the cervical spine was obtained immediately postoperatively at 3 and 6 months to assess hematoma, infection, and swelling. Computed tomography of the operated cervical spine segment was performed to assess bone density, expressed in Hounsfield units. RESULTS: Three-dimensional analysis of segmental motion (medio-lateral, cranio-caudal and anterior-posterior) did not reveal any statistical difference between both groups at any time postoperatively (P>0.05). Fusion rate and speed evaluated on Radiostereometric analysis and computed tomography of cervical spine segment were similar in both groups. MRI of cervical spine did not show any pathology, especially hematoma and infection. The VAS and NDI did not differ between both groups after 6 months (P>0.05). CONCLUSIONS: Anterior plate fixation by using a bioresorbable plate has the same fusion progress and stability as titanium. During the study, no complications like soft tissue swelling and infection occurred.

Tenodesis of the long head of biceps brachii: cyclic testing of five methods of fixation in a porcine model.

For pathologies of the long head of the biceps brachii, various surgical treatment options have been described, ranging from tenotomy to different open and arthroscopic techniques for tenodesis. We analyzed the biomechanical properties of 5 widely used operative techniques for tenodesis of the long head of the biceps brachii: an interference screw (7 x 23-mm Arthrex BioTenodesis screw), a suture anchor (5 x 15-mm Arthrex BioCorkscrew), a ligament washer, the keyhole technique, and the bone tunnel technique. Ten porcine humeri for each technique were used to evaluate the ultimate failure load and cyclic displacement. Tenodesis with the interference screw showed a significantly greater ultimate failure load compared with every other technique (480.9 +/- 116.5 N, P < .005) and the least displacement after 200 cycles, significantly less in comparison to the keyhole and bone tunnel techniques (4.28 +/- 1.44 mm, P < .05). Interference screw fixation has superior biomechanical properties with respect to cyclic displacement and primary fixation strength.

The ProDisc-C prosthesis: clinical and radiological experience 1 year after surgery.

STUDY DESIGN: This is a prospective randomized and controlled study, approved by the local ethical committee of Saarland (Germany). OBJECTIVE: The aim of the current study was to analyze segmental motion following artificial disc replacement using disc prosthesis over 1 year. A second aim was to compare both segmental motion as well as clinical result to the current gold standard (anterior cervical discectomy and fusion [ACDF]). SUMMARY OF BACKGROUND DATA: ACDF may be considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. However, fusion may result in progressive degeneration of the adjacent segments. Therefore, disc arthroplasty has been introduced. Among these, artificial disc replacement seems to be promising. However, segmental motion should be preserved. This, again, is very difficult to judge and has not yet been proven. METHODS: A total of 49 patients with cervical disc herniation were enrolled and assigned to either study group (receiving a disc prosthesis) or control group (receiving ACDF, using a cage with bone graft and an anterior plate). Roentgen stereometric analysis (RSA) was used to quantify intervertebral motion immediately as well as 3, 6, 12, 24, and 52 weeks after surgery. Also, clinical results were judged using visual analog scale and neuro-examination at even RSA follow-up. RESULTS: Cervical spine segmental motion decreased over time in the presence of disc prosthesis or fusion device. However, the loss segmental motion is significantly higher in the fusion group, when looked at 3, 6, 12, 24, and 52 weeks after surgery. We observed significant pain reduction in neck and arm after surgery, without significant difference between both groups. CONCLUSION: Cervical spine disc prosthesis remains cervical spine segmental motion within the first 1 year after surgery. The clinical results are the same when compared with the early results following ACDF.

Biomechanical properties of patellar and hamstring graft tibial fixation techniques in anterior cruciate ligament reconstruction: experimental study with roentgen stereometric analysis.

BACKGROUND: Reliable fixation of the soft hamstring grafts in ACL reconstruction has been reported as problematic. HYPOTHESIS: The biomechanical properties of patellar tendon (PT) grafts fixed with biodegradable screws (PTBS) are superior compared to quadrupled hamstring grafts fixed with BioScrew (HBS) or Suture-Disc fixation (HSD). STUDY DESIGN: Controlled laboratory study with roentgen stereometric analysis (RSA). METHODS: Ten porcine specimens were prepared for each group. In the PT group, the bone plugs were fixed with a 7 x 25 mm BioScrew. In the hamstring group, four-stranded tendon grafts were anchored within a tibial tunnel of 8 mm diameter either with a 7 x 25 mm BioScrew or eight polyester sutures knotted over a Suture-Disc. The grafts were loaded stepwise, and micromotion of the graft inside the tibial tunnel was measured with RSA. RESULTS: Hamstring grafts failed at lower loads (HBS: 536 N, HSD 445 N) than the PTBS grafts (658 N). Stiffness in the PTBS group was much greater compared to the hamstring groups (3500 N/mm versus HBS = 517 N/mm and HSD = 111 N/mm). Irreversible graft motion after graft loading with 200 N was measured at 0.03 mm (PTBS), 0.38mm (HBS), and 1.85mm (HSD). Elasticity for the HSD fixation was measured at 0.67 mm at 100 N and 1.32 mm at 200 N load. CONCLUSION: Hamstring graft fixation with BioScrew and Suture-Disc displayed less stiffness and early graft motion compared to PTBS fixation. Screw fixation of tendon grafts is superior to Suture-Disc fixation with linkage material since it offers greater stiffness and less graft motion inside the tibial tunnel. CLINICAL RELEVANCE: Our results revealed graft motion for hamstring fixation with screw or linkage material at loads that occur during rehabilitation. This, in turn, may lead to graft laxity.