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.

[Arthroscopic treatment of psoas impingement]. / Arthroskopische Behandlung des Psoasimpingements.

OBJECTIVE: Tenotomy of the psoas tendon in symptomatic internal coxa saltans or psoas impingement should relieve pain. INDICATIONS: Indicated in conservative treatment-resistant internal coxa saltans and in psoas impingement. CONTRAINDICATIONS: Contraindications are symptomatic psoas pathologies in hip dysplasia patients. SURGICAL TECHNIQUE: Three different procedures exist with the arthroscopic technique, in which the psoas tenotomy can be performed at one of three different levels. These are the arthroscopic transcapsular, the endoscopic extra-articular, and the arthroscopic central techniques. POSTOPERATIVE MANAGEMENT: Forearm crutches are recommended for approximately 2-4 weeks as well as physiotherapy to strengthen the hip flexors. RESULTS: A literature-based comparison could reveal no difference between the extra-articular and transcapsular techniques. Particularly in the long term was no loss of strength evident. Various different authors describe the techniques as good, finding neither complications nor recurrence of internal snapping hip.

Compression arthrodesis of the rheumatoid ankle and hindfoot.

The reported frequency of involvement of the rheumatoid ankle and hindfoot varies between 9% and 70%. Fusion of the ankle joint, the subtalar, talonavicular, or calcaneocuboidal joint (Chopart's joint) or all of them is the preferred method of treatment for severe rheumatoid involvement causing pain, instability, and/or severe deformity. Ankle arthroplasty is indicated rarely. Pantalar arthrodesis is performed more frequently than talonavicular fusion or ankle fusion. Reported rates of fusion after compression arthrodesis of the ankle joint vary from 65% to 90%, averaging 80% to 85%. Higher success rates of as high as 95% were obtained with internal lag screw fixation as proposed by Wagner. The result of various combinations of arthrodesis (n = 54) of the ankle joint, the subtalar joint, and Chopart's joint in 43 patients with rheumatoid arthritis operated on in a 10-year period from 1984 through 1993 are presented. In all cases internal fixation by lag screws according to Wagner was used with a modified lateral approach incorporating osteotomy of the distal fibula. The technique is described in detail. Solid fusion was obtained in 21% of the cases after 8 weeks, in 9% of the cases after 12 weeks, and in 92% of the cases after 16 weeks. In 8% (3 patients) revision because of delayed union or nonunion eventually led to bony fusion. Postoperative pain, walking capacity, gait, and the subjective outcome were assessed. Complications occurred in 16%, revision was performed in 11.6% of the cases; in all cases healing was obtained. Overall patient satisfaction was 93%.

[Pharmacokinetic studies following 2 and 4-week Felbinac gel administration to the knee joint]. / Pharmakokinetische Untersuchungen nach zwei- bzw. vierwöchiger Felbinac-Gel-Applikation am Kniegelenk.

Twelve patients with osteoarthrosis were locally treated with Felbinac Gel (biphenyl acetic acid (BPAA) 3%) three times daily for 14 days (five patients), 28 days (six patients) or 42 days (one patient) before elective knee joint surgery. BPAA plasma concentrations as of the seventh day of treatment were steady at between 423 and 1040 ng/ml. In surgery, synovial and tissue samples were taken to determine BPAA concentrations. Moderate and sometimes higher synovial BPAA levels in the treated knee joint compared to the contralateral knee seem to indicate a combined direct and systemic absorption. The highest BPAA concentrations (1497-13939 ng/g) were measured in the skin. Drug levels in the synovial membrane (36-994 ng/g), the synovia (104-768 ng/ml), tendon (less than 10-197 ng/g), cartilage (less than 10-109 ng/g), muscle (12-101 ng/g), and subcutis (16-97 ng/g) were lower. BPAA neither accumulates in the skin, nor in any other peri-articular tissue. A steady state was reached as of the 14th day of treatment at the latest. None of the patients reported any local or systemic side effects.