Results after arthroscopic treatment of iliopsoas impingement after total hip arthroplasty.

BACKGROUND: A cause of groin pain after total hip arthroplasty (THA) is mechanical irritation or impingement of the iliopsoas tendon. The incidence is about 4%. If conservative therapy fails, an arthroscopic release of the iliopsoas tendon can be performed. The aim of the study was to assess the mid-term clinical outcome after arthroscopic release. We hypothesize that good results can be achieved by a minimally invasive endoscopic procedure. METHODS: Using our in-house database, all patients who received an endoscopic release of the iliopsoas tendon due to mechanical irritation after THA were identified. Inclusion criteria were mechanical irritation of the iliopsoas tendon after cementless THA with minimal acetabular component prominence. Exclusion criteria were marked prominence of the acetabular component and groin pain after THA for any other reason. In these patients, the modified Harris Hip Score (mHHS), the pain level using the numerical analogue scale and the UCLA Activity Score were measured. The mean follow-up period was 7 ± 3.8 (2.6-11.7) years. RESULTS: 25 patients were identified in whom an arthroscopic release of the iliopsoas tendon had been performed since 2007. The data of 20 patients were available at follow-up. The gender ratio was 1:1, the average age at the time of arthroscopy was 59 ± 27.7 (52-78) years. The average interval between THA and arthroscopy was 6.3 ± 4.0 (1.7-15) years. The mHHS showed a significant improvement from preoperative 31.2 ± 9.8 (17.6-47.3) to 82.0 ± 9.8 (46.2-100) points (p = 0.001). The pain level on the NAS decreased significantly from 8.5 ± 1.2 (7-10) to 2.5 ± 1.8 (0-6) points (p = 0.001). The activity level based on the UCLA Activity Score raised from 4.0 ± 2.7 (0-7) to 6.5 ± 1.8 (3-9) (p = 0.09). CONCLUSION: Mechanical irritation and impingement of the iliopsoas tendon is an important diagnosis to be considered in persistent groin pain after total hip arthroplasty. In failure of non-operative treatment, good clinical results can be achieved with arthroscopic release and the pain level can be significantly reduced. LEVEL OF EVIDENCE: IV.

Assessment of acetabular chondral damage and labral pathologies via direct MR arthrography: specialization matters.

AIMS: To compare the diagnostic accuracy of investigators from different specialities (radiologists and orthopaedic surgeons) with varying levels of experience of 1.5 T direct magnetic resonance arthrography (dMRA) against intraoperative findings in patients with femoroacetabular impingement syndrome (FAIS). METHODS: A total of 272 patients were evaluated with dMRA and subsequent hip arthroscopy. The dMRA images were evaluated independently by two non-hip-arthroscopy-trained orthopaedic surgeons, two fellowship-trained musculoskeletal radiologists, and two hip-arthroscopy-trained orthopaedic surgeons. The radiological diagnoses were compared with the intraoperative findings. RESULTS: Hip arthroscopy revealed labral pathologies in 218 (79%) and acetabular chondral lesions in 190 (69%) hips. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for evaluating the acetabular labral pathologies were 79%, 18%, 79%, 18%, and 66% (non-hip-arthroscopy trained orthopaedic surgeons), 83%, 36%, 83%, 36%, and 74% (fellowship-trained musculoskeletal radiologists), and 88%, 53%, 88%, 54% and 81% (hip-arthroscopy trained orthopaedic surgeons). The sensitivity, specificity, PPV, NPV and accuracy of dMRA for assessing the acetabular chondral damage were 81%, 36%, 71%, 50%, and 66% (non-hip-arthroscopy trained orthopaedic surgeons), 84%, 38%, 75%, 52%, and 70% (fellowship-trained musculoskeletal radiologists), and 91%, 51%, 81%, 73%, and 79% (hip-arthroscopy trained orthopaedic surgeons). The hip-arthroscopy trained orthopaedic surgeons displayed the highest percentage of correctly diagnosed labral pathologies and acetabular chondral lesions, which is significantly higher than the other two investigator groups (p < 0.05). CONCLUSION: The accuracy of dMRA on detecting labral pathologies or acetabular chondral lesions depends on the examiner and its level of experience in hip arthroscopy. The highest values are found for the hip-arthroscopy-trained orthopaedic surgeons. LEVEL OF EVIDENCE: Retrospective cohort study; III.

[Anatomic reconstruction of hip joint biomechanics: conventional vs. short-stem prosthesis]. / Die anatomische Rekonstruktion des Hüftgelenks: ein Vergleich von Kurz- und Standardschaft.

BACKGROUND: Currently, short cementless femoral stems are alternative implants to treat osteoarthritis in young patients with sufficient bone quality in order to get a more proximal load transfer. The purpose of the present study was to biomechanically compare joint reconstructions resulting from implantations of a short-stemmed and a conventional hip replacement. METHODS: 100 patients (50 short-stemmed and 50 conventional) were retrospectively examined. For evaluation of biomechanical parameters standardised pre- and postoperative X-rays (pelvic AP views) were used and digitally analysed. RESULTS: The horizontal femoral off-set increased within both groups (short: 2.0 mm and conventional: 3.3 mm), with a significant increase in the conventional group. The hip centre of rotation was significantly medialised after both procedures (short: 6.0 mm and conventional: 4.2 mm). Limb length was shorter preoperatively at the arthroplasty side, but increased thereafter (short: 2.1 mm and conventional: 2.6 mm). Compared to the native contralateral side the limb length was almost equal after THA (short: 0.7 mm and conventional: 0.8 mm). CONCLUSIONS: Our study shows that an almost anatomic reconstruction of hip joint biomechanics is possible with a short-stemmed prosthesis compared to a conventional stem, regarding limb length, centre of rotation and offset.

[Anatomic reconstruction of hip joint biomechanics with the bone preserving Silent Micro Hip™ prosthesis]. / Anatomische Rekonstruktion des Hüftgelenks mit der schenkelhalserhaltenden Silent Micro Hip™.

BACKGROUND: The design and the surgical technique of the Silent Micro Hip™ are different compared to other hip stems due to a conical shape for fixation within the metaphyseal femur. The purpose of the present study was to evaluate hip joint biomechanics of the Silent Micro Hip™ in comparison to other implants. Implant-specific differences are highlighted. MATERIAL AND METHOD: 150 consecutive patients (each group 50 Silent Micro Hip™, Nanos™ and SL-Plus™ MIA) were analysed retrospectively. For evaluation of biomechanical parameters pre- and postoperative X-rays (pelvic AP views) were used. RESULTS: The horizontal femoral offset and the limb length showed no significant difference between the Silent Micro Hip™ and the Nanos™ or SL-Plus™ MIA stem at the reconstructed hip. An almost anatomic reconstruction of hip joint biomechanics was reached with all three types of implants. CONCLUSIONS: The Silent Micro Hip™ allows for almost anatomic reconstruction of hip joint biomechanics. Short-term results support the bone-preserving reconstruction with a proximal femoral load transfer. Further studies on the mid- and long-term outcomes are ongoing.

[ACL reconstruction in skeletally immature patients]. / Ersatz des vorderen Kreuzbandes bei Kindern und Jugendlichen mit offenen Wachstumsfugen.

AIM: The treatment of choice for skeletally immature patients with anterior cruciate ligament (ACL) deficiency is an ACL reconstruction. In a retrospective study we analysed the clinical results after ACL reconstruction in skeletally immature patients. MATERIAL AND METHOD: In 55 immature patients the ACL was replaced with a four strand-hamstring graft in an anatomic transepiphyseal origin. The fixation was by means of an extracortical button femoral and a suture washer or staple tibial. Patient mean age at operation was 13 years (8 to 16 years). RESULTS: The mean follow-up was at 3.2 years (1 to 7.5 years) postoperatively. The objective IKDC 2000 score was 90.7 % normal or almost normal values. The mean Lysholm score was 94.1 points (70 - 100), the mean Cincinnati knee score was 93.9 points (76 - 100) and 88 % of the patients went back to normal or almost normal sports according to the Tegner score. Stability testing performed with the KT-1000 arthrometer was 1.0 mm (0 - 4 mm) (preoperative average 5.8 mm). The traumatic re-rupture rate was 5.5 %. In two additional cases a partial rupture of the graft was analysed by arthroscopy. Growth deformities or leg length differences were not seen in any case. CONCLUSION: ACL reconstruction with hamstrings and extracortical fixation showed good results and might be the treatment of choice in immature patients. The complication rate was low and there were no postoperative growth deformities.

[ACL reconstruction in skeletally immature patients]. / Ersatz des vorderen Kreuzbandes bei Kindern und Jugendlichen mit offenen Wachstumsfugen.

AIM: The treatment of choice for skeletally immature patients with anterior cruciate ligament (ACL) deficiency is an ACL reconstruction. In a retrospective study we analysed the clinical results after ACL reconstruction in skeletally immature patients. MATERIAL AND METHOD: In 55 immature patients the ACL was replaced with a four strand-hamstring graft in an anatomic transepiphyseal origin. The fixation was by means of an extracortical button femoral and a suture washer or staple tibial. Patient mean age at operation was 13 years (8 to 16 years). RESULTS: The mean follow-up was at 3.2 years (1 to 7.5 years) postoperatively. The objective IKDC 2000 score was 90.7 % normal or almost normal values. The mean Lysholm score was 94.1 points (70-100), the mean Cincinnati knee score was 93.9 points (76-100) and 88 % of the patients went back to normal or almost normal sports according to the Tegner score. Stability testing performed with the KT-1000 arthrometer was 1.0 mm (0-4 mm) (preoperative average 5.8 mm). The traumatic re-rupture rate was 5.5 %. In two additional cases a partial rupture of the graft was analysed by arthroscopy. Growth deformities or leg length differences were not seen in any case. CONCLUSION: ACL reconstruction with hamstrings and extracortical fixation showed good results and might be the treatment of choice in immature patients. The complication rate was low and there were no postoperative growth deformities.

[Anterior cruciate ligament reconstruction with hamstring tendons in the young]. / Die vordere Kreuzbandplastik mit Hamstringsehnen bei Kindern und Jugendlichen.

Regarding the controversial discussion about how and when to operate a patient with an ACL lesion and still open physes,we routinely perform ACL reconstruction in those patients. We evaluated 30 patients with a mean age of 14.2 years at the time of operation (range: 10-18) and a mean follow-up of 30.8 months (range: 13-77). The ACL reconstruction was performed using a four-strand hamstring graft. Fixation was strictly extracortical using an endobutton and a suture washer. The placement of the graft was transepiphyseal. Using the IKDC score, 86.7% were classified as normal or nearly normal. In three cases an ACL insufficiency recurred during the first 12 months postoperatively. There was no growth disturbance. Expecting a poor outcome when treating an ACL lesion conservatively during the growth period and carefully performing the operation, we were able to show that the method provided satisfactory results and should be considered an operative method of choice.

Clinical evaluation of meniscus repair with a bioabsorbable arrow: a 2- to 3-year follow-up study.

In a clinical study with the bioabsorbable Bionx Meniscus Arrow we prospectively evaluated 113 consecutive patients (113 menisci) after all-inside meniscus repair. Repairs were performed in either the medial (80.5%) or lateral (19.5%) posterior horn in the red-red or red-white meniscal zone; 66% of patients underwent concomitant ACL reconstruction. Assessment was based on history, clinical examination, and Lysholm [37] and Cincinnati Knee Scores. After a mean follow-up was 33 months (range 24-43; n=105) 21 (20%) patients showed signs and symptoms consistent with a meniscus tear (16 medial, 5 lateral) and underwent partial meniscectomy. In 11 (52%) of the revised patients concomitant ACL reconstruction was performed; 4 (19%) of revised patients were older than 35 years. In the nonrevised the average Lysholm Score was 92.5 and the average Cincinnati Score 90.4. Two patients showed a distinct femoral cartilage damage. Patient's age did not significantly affect the revision rate. Meniscus repair with the bioabsorbable arrow leads to clinical results comparable to those of traditional suture techniques. When stabilized, patients with concomitant ACL reconstruction showed comparable results to patients without ACL rupture. The simple and time saving all-inside insertion obviates the need for additional incisions and avoids knot tying. A proper tear selection and arrow positioning is necessary and should avoid cartilage damage.

Arthroscopic partial lateral meniscectomy in an otherwise normal knee: Clinical, functional, and radiographic results of a long-term follow-up study.

PURPOSE: To determine the clinical, functional, and radiographic long-term results of patients who underwent arthroscopic partial lateral meniscectomy in an otherwise normal knee. TYPE OF STUDY: This was a retrospective case-control study. METHODS: Between 1982 and 1991, 107 arthroscopic partial lateral meniscectomies were performed; 75 of these patients had an isolated lateral meniscal tear and their data were evaluated using the Lysholm score and a questionnaire recording patients' subjective satisfaction. Radiographic analysis was performed according to the Jäger-Wirth classification and Fairbank changes. RESULTS: All 75 patients were examined by questionnaire, 55 underwent physical examination, and 58 had radiographic analysis. The follow-up period ranged from 5 to 15 years. Excellent and good Lysholm score results decreased from 77% at maximal improvement to 66% at follow-up; 43% of patients maintained their level of maximal improvement, 78% showed one or more Fairbank changes at follow-up, and using the Jäger-Wirth score, 84% showed radiographic deterioration. CONCLUSIONS: Although deterioration of functional and especially radiographic results occurred after arthroscopic partial lateral meniscectomy, the number of good results, even with mean follow-up of 12.3 years, is remarkable. There was a high percentage of radiographic changes in our study, but there is no significant correlation between them and subjective symptoms or between them and functional outcome. We believe that careful meniscectomy provides good results for a long period of time but, the longer the follow-up, the more radiographic changes have to be expected; when meniscal refixation is possible, it should be performed.