Irritation der Iliopsoassehne nach totalendoprothetischem Hüftgelenkersatz

Chronic irritation of the iliopsoas tendon is a rare cause of persistent pain after total joint replacement of the hip. In the majority of cases, pain results from a mechanical conflict between the iliopsoas tendon and the anterior edge of the acetabular cup after total hip arthroplasty. Pain can be reproduced by active flexion of the hip and by active raising of the straightened leg. In addition, painful leg raising against resistance and passive hyperextension are suggestive of an irritation of the iliopsoas tendon. Symptoms evolve from a mechanical irritation of the iliopsoas tendon and an oversized or retroverted acetabular cup, screws penetrating into the inner aspect of the ilium, or from bone cement protruding beyond the anterior acetabular rim. The diagnosis may be assumed on conventional radiographs and confirmed by CT scans. Fifteen patients with psoas irritation after total hip replacement are reported on. Eleven patients were treated surgically. The acetabular cup was revised and reoriented with more anteversion in six patients, isolated screws penetrating into the tendon were cut and leveled in three patients, and prominent bone cement in conflict with the tendon was resected once. A partial release of the iliopsoas tendon only was performed in another patient. Follow-up examination (range: 11-89 months) revealed that nine patients were free of pain and two patient had mild residual complaints. Psoas irritation in combination with total hip replacement can be prevented by a correct surgical technique, especially with proper selection of the cup size and insertion of the acetabular cup avoiding a rim position exceeding the level of the anterior acetabular rim.     

Verlauf der periprothetischen Knochendichte nach Hüfttotalendoprothesenimplantation

Zusammenfassung Bei 81 Patienten wurden mittels DEXA die Veränderungen der periprothetischen Knochendichte über einen Zeitraum von 1 Jahr nach Implantation einer zementfreien Hüfttotalendoprothese untersucht. Implantiert wurden 4 Endoprothesentypen (Vision 2000/Duraloc, ALPHA-Fit/ALPHA-Lock Plus, CLS/Allofit, Mayo/Trilogy). Aus den Messungen sollten Hinweise auf den Einfluss des Prothesentyps sowie der knöchernen Ausgangssituation am Femur auf die Reaktion des Knochens gewonnen werden.Die stärksten Abnahmen der Knochendichte fanden sich bei allen Stieltypen in der Region des Calcar femoris, geringste Veränderungen waren distal sowie medial der Prothesenspitze zu finden. Bei Prothesen mit kürzerem Stiel war die Knochendichteabnahme insgesamt deutlich niedriger als bei Prothesen mit längerem Stiel.Mit wachsender Prothesengröße wurde bei proximal porös beschichteten Stielen aus Kobaltchrom häufiger eine proximale Atrophie beobachtet, beim Prothesenstiel aus Titanlegierung mit komplett aufgerauter Oberfläche nahm dabei die distale Hypertrophie zu. Ein niedriger präoperativer Kortikalis-Markraum-Index verstärkte bei proximal porös beschichteten Prothesen die proximale Atrophie und führte beim Prothesenstiel mit komplett aufgerauter Oberfläche distal vermehrt zur Hypertrophie ohne proximale Atrophie.     

Hüftgelenkersatz mit der zementfreien Spiron-Schenkelhalsprothese

Objective

Cementless total hip arthroplasty with preservation of femoral neck and natural load transmission. Restoration of joint function and alleviation of pain.

Indications

Osteoarthritis of the hip or femoral head necrosis in younger patients.

Contraindications

Patients biologically >?65 years. Destructed or discontinued femoral neck. Pathologic hip formation: short femoral neck, severe enhanced or reduced CCD angle. Body mass index (BMI) >?30 (relative contraindication). Manifest osteoporosis. Necessity of immediate full weight bearing. Heavy smoking (relative contraindication). Ongoing chemotherapy.

Surgical technique

Anterolateral approach to the hip joint. Exposition of the femoral neck and resection of the femoral head at its lateral margin. Preparation of the acetabulum and insertion of a common acetabular component. Positioning of the center pin into the femoral neck. Face milling of the femoral neck butt. Preparation of the femoral neck with the Spiron drill bit. Insertion of the Spiron prosthesis. Trial reduction with a trial head. Substitution by the definitive head (cone 12/14 mm). Wound closure.

Postoperative management

Low centred X-ray of the pelvis and cross table view of the hip joint. Physiotherapy and partial weight bearing for 6 weeks. Prevention of deep vein thrombosis until achievement of full weight bearing.

Results

A total of 28 Spiron prosthesis were implanted in 26 patients (15 men, 11 women, mean age 51 years [range 34–64 years], mean BMI 28 kg/m² [range 21–39 kg/m²]) from August 2009 to January 2012. Diagnoses: 13 cases of primary osteoarthritis, 8 cases of secondary osteoarthritis, 5 cases of femoral head necrosis, and 2 cases of posttraumatic osteoarthritis. The mean surgery length was 93 min (range 70–121 min), the mean hospital stay was 9 days (range 6–16 days). Blood transfusion was not necessary in any of the cases. There were no immediate complications such as deep vein thrombosis, surgery requiring secondary bleeding, wound infection, nerve palsy, or dislocation of the hip. Postoperative radiologic examinations showed an average leg lengthening of 3 mm (range ?10–19 mm). No varus deviation of the prosthesis was observed. The Harris Hip Score improved from 55.4 points (range 33.5–76.9 points) preoperative to 90.5 points (range 75.7–99.9 points) 3 months postoperative. In 1 case with aseptic loosening, replacement surgery was performed without complications.     

Alloarthroplastischer Hüftgelenkersatz mit dem Staffelstein-Score

Background

The aim of the study was to evaluate the effectivity of rehabilitation procedures performed for several weeks after total hip arthroplasty and to analyze the factors influencing rehabilitation results.

Methods

The data of 141 patients following total hip replacement were analyzed comparatively, using the Staffelstein score, both during admission and discharge. Of the 141 patients, 93 (66%) were female and 48 (34%) male, with an average age of 74.9 years. The score according to Staffelstein was taken into consideration in the questionnaire.

Results

The average Staffelstein score on admission in patients undergoing total hip replacement was 73.1 points. At discharge an average of 103.2 points was reached after rehabilitation treatment. This represents a significant difference (<0.001). The result of rehabilitation was independent of sex, age, or weight bearing.

Conclusion

With this study and the use of the Staffelstein score we were able to establish the effectivity of rehabilitation procedures performed for several weeks after total hip arthroplasty. The rehabilitation results were independent of gender, age, and weight bearing.     

Ergebnisse der Hüftgelenksarthrodese nach Küntscher

Zusammenfassung Die Hüftgelenksarthrodese nach Küntscher wird einer kritischen Prüfung unterzogen. Nachuntersuchungen von 30 Patienten ergeben nur fünfmal klinisch und viermal röntgenologisch eine völlige Versteifung des Hüftgelenkes. Auch bei solider Osteosynthese reicht die vorgenommene Teilresektion des Hüftgelenkes nicht aus, um eine Ankylose sicher zu gewährleisten. Bei einer erheblichen Anzahl trat eine Lockerung der Nägel z. T. mit Verlagerung und Fraktur derselben in Erscheinung.Als Nebenbefund konnte bei mehr als der Hälfte aller Fälle eine Verbreiterung des Gelenkspaltes und vielfach auch eine günstige Beeinflussung der osteodystrophen Veränderungen festgestellt werden, ein Befund, der mit der Regenerationsfähigkeit des Gelenkknorpels in Zusammenhang gebracht wird.Mit 12 Textabbildungen (20 Einzelbilder)     

Minimal-invasiver vs. transglutealer Hüftgelenkersatz

Background

The aim of this prospective randomized study was to compare the results after total hip replacement (THR) using an MIS approach versus a regular transgluteal approach (Bauer approach).

Method

We compared 20 THRs using a modified Watson-Jones minimally invasive approach (MIS group) with 20 conventionally performed THRs using a Bauer approach (control group). In all cases, the same implants (Trilogy cup, MAYO stem) were used. The Harris Hip Score (HHS), the visual analogue scale, myoglobin level, and creatinine kinase level were measured preoperatively and up to 3 months postoperatively.

Results

Advantages of the MIS group were evaluated using the HHS in the categories of activity and range of motion 6 weeks postoperatively. In terms of function, gait, and total HHS, we found benefits in the MIS group 6 and 12 weeks postoperatively. Up to 48 h postoperatively, patients in the MIS group had lower myoglobin blood levels. No differences were found in creatinine kinase levels, pain sensation as measured by visual analogue scale, or implant positioning.

Conclusion

Use of the minimally invasive Watson-Jones approach shows advantages compared with the transgluteal Bauer approach 6 and 12 weeks postoperatively. Up to now there has been no prospective randomized clinical study that has definitely shown the superiority of the minimally invasive procedure. For that reason, the conventional approaches in THR are still the gold standard.     

Endoprothetischer Hüftgelenkersatz bei zerebralparetischen Patienten

BACKGROUND: The treatment of painful osteoarthritis of the hip in cerebral palsy requires a therapy concept that considers the pathoanatomical features and adapts the treatment to the individual physical and mental abilities. Femoral head resection has been proven be effective in severely dislocated hip joints in completely immobilized patients, whereas no satisfactory outcome is achieved in those patients with sufficient walking ability and moderate expression of spasticity. RESULTS: The following study investigates the results of total hip replacement (THR) in patients with tetraspastic cerebral palsy. Between 1992 and 2004, 19 total hip arthroplasties were performed in 175 patients with an average follow-up of 4,6 years. In all patients the walking ability improved significantly; 84% of the patients were pain free. Aseptic loosening of the femoral component was registered in one patient. A periprosthetic fracture in another patient required the implantation of a modular non-cemented femoral component. CONCLUSION: In this study total hip arthroplasty represents an important expansion of operative treatment options in secondary osteoarthritis of cerebral palsy in selected and cooperative patients. Taking the contradictions into consideration (severe athetosis, absence of adequate weight bearing, severe pelvic obliquity), THR promises to be an effective alternative to femoral head resection with significant pain reduction and improvement of walking abilities.     

Diagnostik und Therapie der Luxation nach Hüfttotalprothesenimplantation

Background

Luxation following endoprosthetic hip replacement represents a frequent and severe complication and is the reason for a relevant number of hip arthroplasty revision interventions. The probability of occurrence of luxation of a total hip arthroplasty is associated with the indications, patient and operation-specific risk factors. Approximately 50 % of luxations after total hip arthroplasty occur within 3 months of the operation (early luxation).

Diagnostics

The diagnostics of luxation of total hip arthroplasty are carried out by clinical and radiological methods. The causative assignment is made by assessment of joint stability, the bony situation (e.g. loosening, periprosthetic fracture and defects) and the soft tissue (e.g. pelvitrochanterian musculature). In cases of clinical and paraclinical signs of infection and of late luxations, a joint puncture is indicated.

Therapy

Therapy decisions are made depending on the cause (e.g. implant malpositioning, pelvitrochanterian insufficiency, impingement, incongruence between head and inlay and combinations of causes). Therapy of acute total hip prosthesis luxation begins with imaging controlled repositioning carried out with the patient under adequate analgesia and sedation. Conservative therapy is carried out by immobilization with a hip joint orthesis or pelvis-leg cast for 6 weeks. Operative therapy strategies for recurrent luxation are restoration of the correct implant position and sufficient soft tissue tension. Larger hip heads, bipolar heads and tripolar cups are more commonly used due to the geometrically lower probability of dislocation (higher jumping distance). Luxation of total hip prostheses due to infection is treated according to the principles of periprosthetic infection therapy. The rate of recurrence of luxation of 30 % is high so that in cases of unsuccessful therapy treatment should best be carried out in a center for revision arthroplasty.

Conclusions

The search for the exact cause of total hip prosthesis luxation is extremely important. A classification is only possible when the exact cause is known and together with patient and implant-specific details the therapeutic approach can be ascertained. In revision operations the intraoperative functional diagnostics must be exactly documented. The reasons for delayed luxations could be prosthesis infections, abrasion and loosening.     

Histologische Befunde nach Hüftgelenksplastik mittels der Judet-Prothese

Ohne Zusammenfassung     

Erfahrungen mit der operativen Behandlung der Perthesschen Hüfterkrankung nach Pitzen

Zusammenfassung Nach einem Überblick über die bisher beschriebenen verschiedenen Methoden der operativen Behandlung der P.K. wird die Nagelung nach Pitzen und die weitere Nachbehandlung, wie sie in der Orthopädischen Universitäts-Klinik, Frankfurt a. M., geübt wird, beschrieben. Das Krankengut wird in 4 Gruppen aufgeteilt, die sich hinsichtlich des morphologischen Zustandes des Hüftkopfkernes und des Verhaltens nach der Nagelung voneinander unterscheiden lassen. Die für die einzelnen Gruppen typischen Verlaufsformen nach der Nagelung werden an Hand von 4 Fällen ausführlich dargestellt. Den operativ behandelten Fällen werden hierauf die konsequent konservativ behandelten Fälle gegenübergestellt. Der Vergleich ergibt eine Abkürzung der Gesamtbehandlungszeit und eine Verbesserung der erzielten Hüftkopfform nach der operativen Behandlung.Mit 4 Textabbildungen (32 Einzelbilder).Herrn Prof. Dr. G. Hohmann zum 75. Geburtstag gewidmet.     

Zum Problem der Symphysenrupturen unter der Geburt nach einseitiger Hüftgelenksversteifung

Zusammenfassung Nach theoretischen biomechanischen Überlegungen über die Beanspruchung der Symphyse nach einseitiger Hüftgelenksversteifung wird das Problem der theoretisch zu erwartenden verstärkten Beanspruchung der Synchondrosis ischio-pubica bei hüftgelenksversteiften Patientinnen durch den Geburtsmechanismus diskutiert. Auf Grund biomechanischer Berechnungen und Überlegungen wäre somit rein theoretisch eine verstärkte Neigung hüftversteifter gravider Patientinnen zu Symphysenlockerungen und Symphysenrupturen zu erwarten.Aus dem Krankengut der Orthopädischen Universitätsklinik Würzburg ließ sich jedoch diese theoretisch zu erwartende verstärkte Irritation der Synchondrosis ischio-pubica bei hüftversteiften graviden Patientinnen nicht nachweisen. Damit scheint die Theorie von Seyss widerlegt zu sein, daß zur Auslösung einer Symphysenruptur neben dem Moment erhöhter Zugspannung ein Zweitschlag, so z. B. eine Geburt, gehört.

---

The problem of stress of the symphysis following hip-arthrodesis or -ankylosis during pregnancy and birth

Summary Beginning with biomechanic theories about stress of symphysis during pregnancy and birth in cases of ankylosis of the hip there is discussed the theoretical expected stress of the synchondrosis ischio-pubica. First we also have awaited — in correspondence with these treatises — a proneness to lysis of symphysis or even rupture of symphysis in all cases of gravid patient with ankylosis of the hip.Reporting our own cases of the Orthopädische Universitätsklinik Würzburg we couldn't realize the expected increased irritating of the synchondrosis pubica. Concluding our results we don't agree to the opinion (of Seyss), that beyond increased tractive power a second beat is necessary for releasing a rupture of symphysis, delivery for example.

     

Diagnose septischer Hüftprothesenlockerung via LeukoScan

Diagnosis of septic loosening of hip endoprosthesis with antigranulocyte scintigraphy (AGS) was analysed. Twenty-one hip prostheses were studied using laboratory tests and, in cases of elevated values, three-phase bone scan (BS) and AGS. Elective SPECT/CT scans were performed. Histologic and microbiologic exams verified the diagnosis.The AGS analysis revealed sensitivity, specificity and accuracy of value 1, while positive and negative predictive values were also 1. BS showed sensitivity of 1 and specificity of 0.33. In three cases, SPECT/CT scans corroborated the AGS interpretation. This diagnostic algorithm proved effective in the detection of septic loosening of hip prostheses. AGS can be avoided without risk of infection being overlooked.     

Luxation nach Hüfttotalendoprothesenrevision

With a dislocation rate of up to 35% after revision total hip arthroplasty (THA), instability is one of the major causes why this procedure fails. Independent factors for patients at risk are age, sex, and the type of revision needed. The surgical approach, implant choice, and positioning of the components are factors that the surgeon can influence to keep the dislocation rate low. Large femoral heads or double mobility (DM) cups can increase the stability of the joint. After detailed failure analysis, targeted use of different technical innovations enhances stability in revision THA and prevents further revisions.     

Der minimalinvasive Hüftgelenkersatz in Rückenlage mit hochgelagertem kontralateralem Bein

OBJECTIVE: Supine positioning of the patient taking into account - the demands of anesthesia in an emergency requiring intubation, - minimal time for sterile draping, - patient position can be adjusted by the assistants, - easier implant positioning due to the supine position. Reduction of operative trauma with earlier mobilization and shorter rehabilitation time compared with conventional technique. Application of standard instruments and implants. INDICATIONS: Coxarthroses, necroses of the femoral head. CONTRAINDICATIONS: For the "gynecologic position": - hip joint arthrodesis of the contralateral side. - flexion of the contralateral side < 20 degrees . For minimally invasive total hip replacement: - severe anatomic deformities. - revision operations. POSITIONING AND SURGICAL TECHNIQUE: Supine position of the patient with the contralateral leg held at approximately 30 degrees flexion in a gynecologic footrest attached to the operating table. Leg support that can be lowered for the leg being operated on. Minimally invasive anterolateral approach without dissection of muscles or tendons. Resection of the femoral neck and removal of the femoral head. Preparation of the acetabulum and implantation of the cup. Hyperextension of the leg by lowering the leg support with subsequent adduction and external rotation beneath the elevated contralateral leg. Preparation of the femur and implantation of the stem with subsequent repositioning and wound closure. RESULTS: 185 total hip replacements were performed with this positioning and surgical technique from September 2004 to June 2005. The first 108 minimally invasive procedures were compared with 117 conventional procedures. The patients operated in minimally invasive technique generally did better in terms of operating time, blood loss, use of analgesics, rehabilitation time, and functional outcomes. In seven patients, shaft fissures occurred within the first 3 months due to too abrupt intraoperative dislocation of the leg (learning curve!), but were all treated by application of cerclage and healed uneventfully.     

Ueber eine zweckmässige Lagerung nach der Hüftgelenkresection

Ohne Zusammenfassung     

Differentialdiagnostische Erwägungen zur Diagnose Hüftdysplasie unter besonderer Berücksichtigung der Rachitis

Ohne ZusammenfassungMit 6 Textabbildungen     

Zur Diagnose der äusseren Echinococcusgeschwülste

Ohne Zusammenfassung