[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.

[Femoroacetabular impingement. Clinical and radiological diagnostics]. / Femoroazetabuläres Impingement. Klinische und radiologische Diagnostik.

A systematic approach to the examination of the hip region is mandatory to identify patients with femoroacetabular impingement. The patients' age, history, and physical examination may lead to the correct diagnosis. Plain radiographs are the imaging modality of first choice. In addition to obvious findings, more subtle changes such as loss of offset at the head-neck transition or acetabular retroversion have to be assessed. For correct analysis, a high quality of the images must be ensured. Therefore, knowledge of the technique used to take the pictures seems essential. With three-dimensional reconstructed computed tomography, asphericities of the head-neck junction or retroversion of the acetabulum may be visualized. In addition to the accurate demonstration of the head-neck junction, magnetic resonance imaging is particularly suitable to reveal pathological conditions of soft tissues such as articular cartilage or labral lesions.

[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.

[Differential diagnosis of hip and groin pain. Symptoms and technique for physical examination]. / Differentialdiagnose von Hüft- und Leistenschmerzen. Symptome und körperliche Untersuchungstechnik.

The differential diagnosis of hip and groin pain with respect to the high frequency of referred pain from the lumbar spine, lower abdomen, and pelvis is demanding. A systematic approach to the hip and groin area is important to identify the origin of pain. Both the history and quality of symptoms and the physical exam are the basics of the diagnostic algorithm. Roentgenograms and possibly an injection with a local anesthetic to the suspected origin of pain often complete the diagnostic work-up.The following report summarizes the typical symptoms of hip and groin disorders. A detailed description of the physical exam including functional tests for impingement, apprehension, adductor-, psoas-, and inguinal-related pain is included.

[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.

[Magnetic resonance tomography and arthrography of the hip joint]. / Magnetresonanztomographie und -arthrographie des Hüftgelenks.

Plain film radiographs represent the imaging of choice for the initial evaluation of pathologies of the hip. However, many lesions of the joint itself and surrounding soft tissues are often not visualized by conventional radiographs. Magnetic resonance imaging (MRI) demonstrates most of these pathologies with high sensitivity and specificity. For further assessment of intra-articular lesions such as labral tears, hyaline cartilage lesions, rupture of the ligamentum teres, and loose bodies, direct MR arthrography after intra-articular administration of contrast medium may be indicated. This article summarizes the technical aspects and the most important indications for MRI and MR arthrography of the hip in correlation with typical imaging findings of the most frequent pathologies.

[Radiological examination of the hip. Analysis of standard projections]. / Radiologische Untersuchung des Hüftgelenks. Analyse der Röntgenstandardprojektionen.

Plain radiography of the hip joint is the imaging modality of first choice. The standard projections are an anteroposterior view of the whole pelvis and a lateral view of the involved hip. Depending on the suspected pathology, different lateral projections are used such as the Lauenstein view, a false profile view, or a lateral cross-table view. Additional projections may be helpful in special indications. For correct analysis and interpretation, the radiographs need to be checked for adequate orientation and exposure. The orthopedic surgeon has to be familiar with the imaging technique of each radiograph and its normal appearance in order to assess the orientation of the pelvis during exposure and to detect even subtle pathology or changes in orientation of the acetabulum or proximal femur.

[Diagnosis of rupture of the anterior cruciate ligament]. / Diagnostik der Ruptur des vorderen Kreuzbandes.

Clinical examination has remained the key for diagnosis of meniscal and ligament lesions of the knee. Economical use of imaging techniques is based on adequate clinical examination. Standard radiographic examination is still a simple and valuable method. Magnetic resonance tomography has made great progress during the past few decades. For this reason, this article centers on this imaging modality.

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.