Arthroskopische Therapie von Knorpelschäden im Hüftgelenk

Background

Cartilage defects at the hip joint present one of the most frequent reasons for hip pains and their subsequent indication for hip arthroscopy. A thorough analysis and therapy based on pathology of the joint is essential for succeeding in any cartilage therapy.

Material and methods

The presented paper is to outline a survey of both the author’s results and of all those published so far on classical hip joint cartilage therapy but also of potentially superior grade of surgery.

Results and conclusion

There has been an increase in more demanding cartilage therapies recently, applied successfully at various other joints as well, being an alternative to the common techniques carried out so far. However, there cannot be deduced any supremacy of those according to the literature available at present. Added to this and considering the specific anatomy of the hip joint there is required still more comprehensive surgical experience.     

Arthroskopische Therapie bei steifem Ellenbogen

Elbow stiffness is often caused by a combination of intrinsic and extrinsic pathological joint alterations. The indications for operative treatment should be considered only after exhausting all conservative therapy options and after a thorough analysis of the etiology, evaluation of the affected structures and the individual requirements of the patient. Arthroscopic arthrolysis of the elbow joint has become established as the standard treatment of moderate functional deficits with a range of motion >60° in the extension-flexion plane and primarily intrinsic alterations, such as free joint bodies, intra-articular ossification and arthrofibrosis. All elbow joint compartments have to be structurally addressed to obtain the best operative outcome. In general, osseous obstacles are treated before the joint capsule is released. Furthermore, a test of joint stability by using a counterbrace is necessary to avoid relapse and treatment failure. Decompression of the ulnar nerve is recommended to avoid secondary nerve damage. Results of arthroscopic arthrolysis showed an improvement in the range of motion from 93° to 118° in 45 patients after 12 months. Close cooperation between the surgeon, patient and therapist is essential to maintain the achieved range of motion in the postoperative period. Postoperative management includes plexus anesthesia and adequate pain medication, frequent physiotherapy and continuous passive motion. Additionally, an extension orthosis is applied for 6 weeks.     

Impingement des Hüftgelenks

Introduction

According to the technical development in hip arthroscopy in recent years there is an increasing demand for joint preserving treatment of hip impingement pathologies. It is important to detect those pathologies and to differentiate them from non-impingement pathologies with similar symptoms.

Methods

A thorough evaluation of the patient’s history should always be the first step. Pain in standing position and at rest may indicate a concomitant degenerative joint disease. Further diagnostic evaluation should be supported by a standard radiography and magnetic resonance imaging (MRI). At the physical examination the active and passive range of motion (ROM) is documented for both hips. Painful mechanical hip impingement has to be assessed and reproduced. A sterile diagnostic intra- or extraarticular infiltration with a local anesthetic may help in differential diagnosis.     

Ergebnisse der Hüftarthroskopie

The frequency of hip arthroscopies has been increasing in recent years as the result of standardization and multiple publications of the operative technique. The aim of this literature review was to provide the surgeon with data indicating the results of different arthroscopic procedures. Analysis of the literature showed that the results of hip arthroscopies mostly depended on the indications. In cases of proper patient selection, the outcome of hip arthroscopy was successful. Preoperative pain could be reduced and function improved in most cases. Good results were especially reported for the removal of loose bodies, treatment of septic coxitis, and the treatment of isolated lesions of the acetabular labrum and the ligamentum teres. In cases of osteoarthritis, hip arthroscopy improved the complaints. Underlying cartilage degeneration reduced the outcome of the treatment of labral and ligamentum teres tears. Symptoms and healing of avascular necrosis of the femoral head were not affected by hip arthroscopy.     

Arthroskopische Fixierung der Typ-II-SLAP-Läsion

Fixation of SLAP II lesions are often difficult because the posterior-superior part of the labrum does not allow good visualization of the glenoid. With our technique, we pass a suture through a needle which is placed in the supraspinous fossa. The suture is tied over the anterior-superior portal and drawn back through the fossa. Visualization of the posterior-superior glenoid is now allowed and the suture anchor can be placed precisely.     

Arthroskopische Rekonstruktion der akuten AC-Gelenk-Instabilität

Acute disruption of the acromioclavicular (AC) joint is a common injury in daily life and sport. Because of the ever increasing physical demands of patients and ever improving arthroscopic skills, stabilization of acute AC joint disruption is nowadays performed arthroscopically in highly specialized departments. Recently several arthroscopic techniques have been described for treatment of acute AC joint disruption. However, complications such as implant failure have also been described in connection with these techniques. This article presents the indications, surgical techniques and also the complications and risks of using an arthroscopic augmentation technique.     

Arthroskopische Behandlung als station?re Leistung

The German diagnosis-related groups (DRG) system has undergone a continuous evolution during the past decade. This is true for arthroscopic surgery as well. This development is triggered by the ongoing development of the surgical techniques as well as the increasing expense of these arthroscopic procedures. These effects must be taken into account by hospital managers. Only an exact understanding of the underlying mechanisms can lead to the desired results and increase performance capacity. The current situation for knee arthroscopy is outlined in this paper.     

Subspinales Impingement des Hüftgelenks

Background

In recent years more evidence has been found that the pathological premature bone contact of the anterior inferior iliac spine (AIIS) with the neck of the femur, the subspinal impingement, is sometimes the underlying principle of painful limitation of hip flexion and is currently treated by AIIS bone resection.

Aim

The aim of this study is a summary and critical discussion of the current literature on subspinal impingement.

Methods

The pathomechanism, nomenclature, anatomy, classification, diagnosis, symptoms and therapy are described based on 15 relevant publications listed in medline.

Conclusion

These parameters and postoperative results of the published cases seem so promising that further case numbers and long-term results can be expected.     

Synoviale Erkrankungen der Hüfte

Synovial diseases and loose bodies are one of the most common indications for hip arthroscopy. Arthroscopic intervention has been reported in the literature for loose bodies, irritating synovial plicae, synovial chondromatosis, pigmented villonodular synovitis (PVNS) as well as rheumatoid and septic arthritis. One major advantage of arthroscopy in comparison to radiological imaging is the ability to inspect, biopsy and treat within one procedure. In contrast to arthrotomy hip arthroscopy avoids the potential risks of extensive surgical exploration which is associated with a higher morbidity and prolonged rehabilitation. Nevertheless, hip arthroscopy cannot be promoted as curative for all synovial disorders. In patients with loose bodies, synovial plicae, septic arthritis at an early stage and to some extent synovial chondromatosis and localized PVNS, curative therapy and full recovery can be achieved. In contrast, in patients with highly active synovial chondromatosis, diffuse PVNS and rheumatoid arthritis, the goal of hip arthroscopy is to enable the correct diagnosis, to provide symptomatic relief and maintain or improve joint function and to decide whether adjuvant therapy, systemic medication or secondary open surgery is necessary. Success or failure of arthroscopic treatment depends on correct patient selection and correct arthroscopic technique.     

Natürlicher Verlauf bei Hüftdysplasie und Operationsergebnisse

Background

The prevalence of hip dysplasia in epidemiological studies ranges from 1–20%. The associated deformity is a risk factor for secondary osteoarthritis (OA) of the hip.

Objective

What is the natural course of hip dysplasia and is it influenced by cofactors? How successful are corrective surgical procedures?

Material and methods

Analysis of published investigations up to 2018 which provide data about the natural course of hip dysplasia and the results of the most important surgical treatment procedures.

Results

The vast majority of published studies confirm a correlation between hip dysplasia and OA. The risk of OA increases with reduced acetabular coverage and severity of instability (subluxation). Long-term survival and functional results after pelvic osteotomies are meanwhile very good, if the procedure is performed in young or middle-aged patients with good congruency of the joints and no relevant OA. Additional deformities (e.?g. cam deformity or femoral torsional malalignment) should be simultaneously addressed and the acetabular fragment needs optimal positioning. Only a few studies with small patient cohorts and short observation times are currently available on the isolated arthroscopic treatment of borderline dysplasia.

Discussion

The importance of hip dysplasia as an established risk factor for secondary OA and the good results of reorientation pelvic osteotomies justify surgical correction when considering the identified indication criteria. Due to a low but relevant potential for complications, surgery should currently not be recommended for asymptomatic patients in adulthood. Potentially relevant cofactors are important for estimation of the natural course as well as the indications for surgical correction.

     

Arthroskopische Behandlungsmöglichkeiten chronischer Schultereckgelenkinstabilitäten

Chronic instability of the acromioclavicular joint (AC joint) can lead to pain, a feeling of instability and weakness of the shoulder. In order to establish an individual treatment concept the diagnostic assessment is based on the history, clinical evaluation and radiological imaging including stress radiographs. Prior to surgical intervention a conservative treatment approach is indicated. Recently more and more arthroscopic and minimally invasive techniques have been described for the treatment of these pathologies although the indications have yet to be clarified. After failure of conservative treatment a minimal arthroscopic AC joint resection can be considered in cases of minor instability, especially when secondary osteoarthritis is the main issue. Moderate forms of AC joint instability can be treated effectively by an additional arthroscopic transfer of the coracoacromial ligament in terms of an all-arthroscopic modified Weaver-Dunn procedure. For severe vertical and horizontal instabilities an arthroscopically assisted autologous tendon graft transplantation for coracoclavicular and acromioclavicular ligament replacement is performed. So far, studies describing the outcome after arthroscopic or minimally invasive stabilization of chronic AC joint dislocations have shown promising results. Nevertheless mid-term and long-term results are still lacking.     

Arthroskopische laterale OSG-Stabilisierung in modifizierter Brostr?m-Gould-Technik

The Brostrom-Gould procedure is an established method for anatomic ligamentous reconstruction of the lateral ankle joint. This article presents the arthroscopic technique and the first results of this procedure. From August 2009 to February 2011 a total of 17 patients (6 male, 11 female) with isolated chronic lateral ankle instability were treated using this technique. Patients with concomitant pathologies were excluded from this investigation. The mean follow-up was 12.5 months (range 6?C26 months). The postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 92.6 (range 61?C100) and the mean Karlsson score was 86.2 (range 42?C100). In one patient the mechanical instability persisted (5.8%) but the other 16 patients (94.0%) were satisfied with the postoperative result and would undergo the same operation again. No postoperative complications occurred.     

Extraartikuläres Weichteil-Impingement des Hüftgelenks

Introduction

Conservative treatment is the gold standard for painful extra-articular snapping abnormalities of the hips caused by the psoas tendon, trochanteric bursitis and the iliotibial band. Arthroscopic tenotomy, bursectomy or tractus release are indicated if conservative management is not successful. In addition to open techniques, various arthroscopic techniques have also been described.

Therapeutic options

There are three different arthroscopic techniques described for psoas tenotomy: the extra-articular method (tenotomy at the level of the lesser trochanter), the transcapsular technique (tenotomy through the peripheral compartment) and the central technique (tenotomy at the level of the anterior rim with distracted hips). Good results have been published for all three methods. The mechanical irritation of the psoas tendon after total hip replacement is a special indication for arthroscopic tenotomy. The results are good and it is less invasive than the complicated cup replacement procedure with fewer complications. A newly described syndrome is iliopsoas impingement where an atypical tear of the labrum at the anterior rim of the acetabulum occurs. Treatment is carried out by arthroscopic refixation of the labrum and tenotomy of the psoas tendon. Open or arthroscopic procedures are recommended to perform a bursectomy or tractus release but comparative studies are currently lacking.

Conclusion

If conservative treatment of internal snapping hip syndrome and mechanical psoas irritation after total hip replacement fails, arthroscopic psoas tendon tenotomy is an effective method. Bursectomy and tractus release for extra-articular snapping hip syndrome can be carried out by open or arthroscopic procedures with similar results. The scientific evidence in other extra-articular abnormalities of the hip remains poor.     

Klinische Untersuchung des Hüftgelenkes des Erwachsenen

Complaints in the region of the hips and pelvis are often difficult to classify. This is due to the fact that pain projection and overlapping can occur; therefore, the complete region of the lumbar spine, pelvis and hips must be considered as a single entity in which alterations can result in radiation throughout the whole region. There are many different anatomical structures within the pelvic region so that the function of various muscle components can be impaired and cause pathological alterations to positional relationships of bony structures or even alterations to other soft tissues, such as ligaments, tendons and labra. In terms of differential diagnostics the groin must be seen as the weak point of the peritoneum and vascular system and taken into consideration. Therefore, a detailed and targeted medical history, functional testing and specific examinations and tests are necessary to narrow down the pathology in question and reach a definitive diagnosis. Orthopedic surgeons must know which conspicuous features can lead to which problems and which anatomical structures are likely to be affected by irritation. The results of the clinical examination are the basis for targeted imaging diagnostics and subsequent therapy.