J.H. Schröder

[Musculoskeletal load analysis. A biomechanical explanation for clinical results--and more?].

ZusammenfassungDer Langzeiterfolg aller Eingriffe an der unteren Extremität ist von der Berücksichtigung der Belastungen durch Muskel- und Gelenkkräfte bei der Planung und der operativen Versorgung abhängig. Detaillierte, patientenspezifische Informationen um die in vivo wirkenden Kräfte und deren Verteilung stehen dem Operateur in der klinischen Routine bis heute jedoch nicht zur Verfügung. Ziel dieser Studie war es, die muskuloskeletalen Belastungen der Hüfte in Abhängigkeit von der Pfannenposition mit Hilfe validierter Verfahren zu ermitteln. Anschließend wurden die rechnerisch ermittelten biomechanischen Parameter mit den Resultaten einer klinischen Studie verglichen. Die Ergebnisse zeigten, dass eine optimale mediolaterale Rekonstruktion des Hüftzentrums die Kräfte am Hüftgelenk minimiert. In Zukunft könnte der routinemäßige Einsatz validierter muskuloskeletaler Belastungsanalysen im Rahmen standardisierter präoperativer Planung und intraoperativer navigationsgestützter Umsetzung signifikant die Langzeitfunktion durch Reduktion des Abriebs der Endoprothese und Optimierung der muskulären Funktionsparameter des Gelenks verbessern.AbstractMechanical loading of the lower extremities due to muscle and joint contact forces plays an important role in orthopaedic and trauma surgery. Detailed, patient specific information on the in vivo forces and their distribution is, however, currently not readily available to the surgeon in clinical routine. The goal of this study was to elucidate the relationship between the position of the cup and the musculoskeletal loading conditions at the hip using validated analyses, and further, to evaluate the predictions of the biomechanical conditions against the results of a clinical study. The results indicate that restoring the anatomical hip centre to its anatomical mediolateral position could help to reduce joint loads and add to the longevity of the reconstruction. The routine use of validated analyses of musculoskeletal loading conditions, such as in the presented example using standardised pre-operative planning and sound intra-operative decision support systems, could contribute to securing a high standard in patient treatment.

[Arthroscopic correction of extra-articular subspinal impingement in the hip joint].

ZusammenfassungWir beschreiben den Fall eines symptomatischen extraartikulären Subspine-Impingements am Hüftgelenk, hervorgerufen durch den pathologischen Kontakt zwischen einer hypertrophen Spina iliaca anterior inferior (SIAI) und dem ventralen Schenkelhals. Die Untersuchung eines 28-jährigen Patienten mit rechtsseitigen belastungsabhängigen Leistenschmerzen und positivem Impingementtest zeigte im Röntgen und CT eine Hypertrophie der SIAI mit Ausdehnung nach kaudal. Bei positivem Infiltrationstest erfolgte die arthroskopische partielle Resektion der SIAI, woraufhin der Patient eine verbesserte und nahezu schmerzfreie Hüftgelenkbeweglichkeit zeigte.AbstractWe report the case of symptomatic extra-articular subspinal impingement in the hip joint caused by a pathological contact between the anterior inferior iliac spine (AIIS) and the femoral neck. A 28-year-old patient presented with activity-related inguinal pain on the right side and a positive anterior impingement test in the clinical examination. Radiological examinations revealed a hypertrophic AIIS with caudal extension below the acetabulum. After a positive injection test confirmed the AIIS as the origin of the pain, arthroscopic correction with partial resection of the AIIS was performed resulting in significant pain relief and improved range of motion.We report the case of symptomatic extra-articular subspinal impingement in the hip joint caused by a pathological contact between the anterior inferior iliac spine (AIIS) and the femoral neck. A 28-year-old patient presented with activity-related inguinal pain on the right side and a positive anterior impingement test in the clinical examination. Radiological examinations revealed a hypertrophic AIIS with caudal extension below the acetabulum. After a positive injection test confirmed the AIIS as the origin of the pain, arthroscopic correction with partial resection of the AIIS was performed resulting in significant pain relief and improved range of motion.

Arthroskopische Korrektur des extraartikulären Subspine-Impingements am Hüftgelenk

ZusammenfassungWir beschreiben den Fall eines symptomatischen extraartikulären Subspine-Impingements am Hüftgelenk, hervorgerufen durch den pathologischen Kontakt zwischen einer hypertrophen Spina iliaca anterior inferior (SIAI) und dem ventralen Schenkelhals. Die Untersuchung eines 28-jährigen Patienten mit rechtsseitigen belastungsabhängigen Leistenschmerzen und positivem Impingementtest zeigte im Röntgen und CT eine Hypertrophie der SIAI mit Ausdehnung nach kaudal. Bei positivem Infiltrationstest erfolgte die arthroskopische partielle Resektion der SIAI, woraufhin der Patient eine verbesserte und nahezu schmerzfreie Hüftgelenkbeweglichkeit zeigte.AbstractWe report the case of symptomatic extra-articular subspinal impingement in the hip joint caused by a pathological contact between the anterior inferior iliac spine (AIIS) and the femoral neck. A 28-year-old patient presented with activity-related inguinal pain on the right side and a positive anterior impingement test in the clinical examination. Radiological examinations revealed a hypertrophic AIIS with caudal extension below the acetabulum. After a positive injection test confirmed the AIIS as the origin of the pain, arthroscopic correction with partial resection of the AIIS was performed resulting in significant pain relief and improved range of motion.We report the case of symptomatic extra-articular subspinal impingement in the hip joint caused by a pathological contact between the anterior inferior iliac spine (AIIS) and the femoral neck. A 28-year-old patient presented with activity-related inguinal pain on the right side and a positive anterior impingement test in the clinical examination. Radiological examinations revealed a hypertrophic AIIS with caudal extension below the acetabulum. After a positive injection test confirmed the AIIS as the origin of the pain, arthroscopic correction with partial resection of the AIIS was performed resulting in significant pain relief and improved range of motion.

The ‘Hip Vacuum Sign’—a new radiographic phenomenon in femoro-acetabular impingement

Femoro-acetabular impingement (FAI) is a frequent cause for groin pain in young and active patients. We discovered a so far undescribed radiographic phenomenon only visible in frog-leg lateral radiographs. The aim of this study was to describe this new radiological sign, to determine its prevalence in a symptomatic population and to investigate the correlation to a potential underlying pathology. We retrospectively reviewed all patients, who had been sent to our clinic between 2010 and 2012 for hip complaints. We excluded patients older than 50 years and patients with advanced osteoarthritis. Two independent investigators blinded to clinical data independently examined all images for the presence, location and dimension of a vacuum phenomenon and a potential underlying hip pathology. We included 242 patients. 137 of them showed clinical and radiological signs of FAI. A hip vacuum phenomenon was identified in 20 of 242 patients (8%). Interestingly, all these patients showed distinct signs of femoro-acetabular impingement. In reference to this, the prevalence of the “Hip Vacuum Sign” was 15% (20/137) in symptomatic patients with FAI. There was no correlation with age or gender. We identified a new radiological sign, the “Hip Vacuum Sign”, in 15% of symptomatic patients with FAI. It was only visible in frog-leg lateral radiographs. We suggest that it represents a subluxation of the femoral head due to a lever mechanism between the femoral neck and the acetabular rim and is, therefore, a hint for a relevant femoro-acetabular impingement mechanism.

Konventionell-radiologische Darstellung des subspinalen Impingements und Koinzidenz mit intraartikulärem Impingement am Hüftgelenk

Background Besides the known intraarticular femoroacetabular impingement (FAI), recently forms of extra-articular impingement of the hip have been increasingly recognized. Recent studies have described an extra-articular impingement between a distal extension of the anterior inferior iliac spine (AIIS) and the femoral neck (AIIS or subspine impingement). Evidently, an association between this subspine impingement and an intraarticular FAI seems to exist. Little is known about the incidence of this impingement type and the value of its radiological diagnostics. The aim of this study was therefore to evaluate the correlation of a subspine impingement with intraarticular femoroacetabular impingement and radiological criteria of subspine impingement. Material and Methods In 2013 arthroscopic correction of intra-articular femoroacetabular impingement was performed in 80 cases. This collective was evaluated for simultaneous intraoperative findings of subspine impingement. In addition, the patients were evaluated for radiological signs of subspine impingement in conventional X-ray. A projection of the AIIS either below the acetabular sourcil or the anterior acetabular rim in an AP pelvis X-ray was considered as a radiological sign of low AIIS formation. These radiological findings were compared with the presence of intraoperative signs for subspine impingement, which are defined as a combination of focal capsule synovitis, labral ecchymosis close to the AIIS and a decreased offset between the acetabular rim and the AIIS. The specificity and sensitivity of the pre-operative radiological signs were calculated. Results A subspine impingement was found in 17 cases (21 %, 3 female, 14 male, mean age 28 years). A projection of the AIIS caudal to the acetabular sourcil in the AP pelvis X-ray was represented in 15 of the 17 cases detected (sensitivity 0.90, specificity 0.88). A projection below the anterior glenoid rim was detectable in 2 cases with symptomatic AIIS impingement (sensitivity 0.12, specificity 1). Conclusion A relevant proportion of patients with intraarticular FAI showed intraoperative signs for an additive extraarticular AIIS impingement. Preoperative pelvic X-rays are helpful with a sensitivity of 90 % in detecting the presence of a distal extension of the AIIS in FAI patients. Evaluation of the preoperative AP pelvis x-ray should include the projection of the AIIS. We recommend evaluation for subspine impingement during routine arthroscopy.

Arthroscopic Treatment for Primary Septic Arthritis of the Hip in Adults

Purpose. Primary septic arthritis is a rare differential diagnosis of acute hip pain in adults. Inspired by the success of all-arthroscopic treatment in pediatric patients, we developed a diagnostic and surgical pathway for our adult patients. Methods. Seven patients, average age 44 ± 13.7 years with acute hip pain since 4.4 ± 2.9 days in the average, were included. Septic arthritis was confirmed by joint aspiration and dissemination was excluded by MRI and standard radiographs. Surgical treatment consisted of immediate arthroscopic lavage using 4 portals for debridement, high-volume irrigation, partial synovectomy, and drainage. Results. Patients were treated in hospital for 12.4 ± 3.1 days (range 7–16 days). WBC and CRP returned to physiological levels. During the mean follow-up of 26.4 ± 19.4 months (range 13–66 months) no patient showed recurrence of infection. The 5 patients with an unimpaired hip joint prior to the infection had a mean modified Harris Hip Score of 94 ± 5.6 points (range 91–100) at final follow-up. Conclusions. Arthroscopic therapy using a minimally invasive approach with low perioperative morbidity for the treatment of primary septic arthritis of the adult hip is able to restore normal hip function in acute cases without dissemination of the infection. Level of Evidence. IV.

Ossäre Tuberkulose als seltene Differenzialdiagnose der Femurkopfnekrose

BACKGROUND We report on a 60-year-old immunocompetent German male patient without risk factors, who had been suffering from pain in the right hip for 8 months. DIAGNOSTICS Radiographs showed destruction of the femoral head with a collapse of the main weight-bearing area, which was interpreted as femoral head necrosis. THERAPY A cement-free total hip prosthesis was then implanted. The femoral head was sent for routine histological analysis and PCR amplification yielded a positive result for Mycobacterium tuberculosis complex DNA, leading to immediate guideline-based tuberculostatic treatment. CONCLUSION Tuberculosis should be considered as a differential diagnosis in the case of destruction of the femoral head, especially in immunocompromised patients, patients with a foreign background or destructive osteoarthritis of the hip with an atypical course. Antibiotic treatment is necessary postoperatively. Under this therapy, a good clinical outcome can be expected comparable to that achieved in patients with primary osteoarthritis without infection.

Ossäre Tuberkulose als seltene Differenzialdiagnose der Femurkopfnekrose@@@Osseous tuberculosis as a rare differential diagnosis of femoral head necrosis

BACKGROUND We report on a 60-year-old immunocompetent German male patient without risk factors, who had been suffering from pain in the right hip for 8 months. DIAGNOSTICS Radiographs showed destruction of the femoral head with a collapse of the main weight-bearing area, which was interpreted as femoral head necrosis. THERAPY A cement-free total hip prosthesis was then implanted. The femoral head was sent for routine histological analysis and PCR amplification yielded a positive result for Mycobacterium tuberculosis complex DNA, leading to immediate guideline-based tuberculostatic treatment. CONCLUSION Tuberculosis should be considered as a differential diagnosis in the case of destruction of the femoral head, especially in immunocompromised patients, patients with a foreign background or destructive osteoarthritis of the hip with an atypical course. Antibiotic treatment is necessary postoperatively. Under this therapy, a good clinical outcome can be expected comparable to that achieved in patients with primary osteoarthritis without infection.

Osseous tuberculosis as a rare differential diagnosis of femoral head necrosis

BACKGROUND We report on a 60-year-old immunocompetent German male patient without risk factors, who had been suffering from pain in the right hip for 8 months. DIAGNOSTICS Radiographs showed destruction of the femoral head with a collapse of the main weight-bearing area, which was interpreted as femoral head necrosis. THERAPY A cement-free total hip prosthesis was then implanted. The femoral head was sent for routine histological analysis and PCR amplification yielded a positive result for Mycobacterium tuberculosis complex DNA, leading to immediate guideline-based tuberculostatic treatment. CONCLUSION Tuberculosis should be considered as a differential diagnosis in the case of destruction of the femoral head, especially in immunocompromised patients, patients with a foreign background or destructive osteoarthritis of the hip with an atypical course. Antibiotic treatment is necessary postoperatively. Under this therapy, a good clinical outcome can be expected comparable to that achieved in patients with primary osteoarthritis without infection.

Arthroskopische Korrektur des extraartikulären Subspine-Impingements am Hüftgelenk@@@Arthroscopic correction of extra-articular subspinal impingement in the hip joint

ZusammenfassungWir beschreiben den Fall eines symptomatischen extraartikulären Subspine-Impingements am Hüftgelenk, hervorgerufen durch den pathologischen Kontakt zwischen einer hypertrophen Spina iliaca anterior inferior (SIAI) und dem ventralen Schenkelhals. Die Untersuchung eines 28-jährigen Patienten mit rechtsseitigen belastungsabhängigen Leistenschmerzen und positivem Impingementtest zeigte im Röntgen und CT eine Hypertrophie der SIAI mit Ausdehnung nach kaudal. Bei positivem Infiltrationstest erfolgte die arthroskopische partielle Resektion der SIAI, woraufhin der Patient eine verbesserte und nahezu schmerzfreie Hüftgelenkbeweglichkeit zeigte.AbstractWe report the case of symptomatic extra-articular subspinal impingement in the hip joint caused by a pathological contact between the anterior inferior iliac spine (AIIS) and the femoral neck. A 28-year-old patient presented with activity-related inguinal pain on the right side and a positive anterior impingement test in the clinical examination. Radiological examinations revealed a hypertrophic AIIS with caudal extension below the acetabulum. After a positive injection test confirmed the AIIS as the origin of the pain, arthroscopic correction with partial resection of the AIIS was performed resulting in significant pain relief and improved range of motion.We report the case of symptomatic extra-articular subspinal impingement in the hip joint caused by a pathological contact between the anterior inferior iliac spine (AIIS) and the femoral neck. A 28-year-old patient presented with activity-related inguinal pain on the right side and a positive anterior impingement test in the clinical examination. Radiological examinations revealed a hypertrophic AIIS with caudal extension below the acetabulum. After a positive injection test confirmed the AIIS as the origin of the pain, arthroscopic correction with partial resection of the AIIS was performed resulting in significant pain relief and improved range of motion.