Martin Hufeland

[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.

Reply to the Letter to the Editor: Is the flexion strength really increased after tenodesis for tendinopathy of the Long Head of the Biceps?

In regard to the other two studies, post-operative strength analysis alone does not allow valid conclusion in regard to improvement of elbow flexion strength. However, the authors agree that pain reduction certainly is a factor that can have an influence on the elbow flexion strength preoperatively. It is not analysed in the study that the increase in flexion strength is solely a result of the tenodesis or can probably be achieved by a biceps tenotomy as well. Whether the elbow flexion strength is partly compensated by intact short head of the biceps is difficult to evaluate but certainly a factor that must be considered. The authors are aware that the present study has some limitations, which are extensively emphasized in the discussion section. In regard to prospective randomized trials comparing tenodesis or tenotomy, the authors agree that high powered studies with a large number of participants are necessary in order to provide further evidence for the selection of the ideal treatment of long head of biceps pathology in our patients. But, as pointed out before, including patients with concomitant rotator cuff repair as in the study initiated by Gurnani et al. does certainly not provide any viable answers. In conclusion, a prospective randomized trial should be conducted on isolated biceps lesion only and must include supination and elbow flexion strength measured preoperatively and post-operatively as well as the evaluation of an objectively defined Popeye sign deformity in order to allow any further conclusion that can influence the choice for either treatment. This type of study has been started in form of a national DVSE multicentre study in 2015, and preliminary results are expected soon. The authors thank Gurnani et al. for their interest in the study and for once again pointing out the limitations and We would like to thank the Gurnani et al. for their interest and comments on our recent article titled “The influence of suprapectoral arthroscopic biceps tenodesis for isolated biceps lesions on elbow flexion force and clinical outcomes” that prospectively evaluates the influence of all-arthroscopic suprapectoral biceps tenodesis for isolated biceps lesions on elbow flexion force, cosmetic and clinical outcome [3]. Gurnani et al. bring up some points of interest. They noted that not tenodesis but pain reduction is the major factor that is responsible for the increase in elbow flexion strength. The writers deduct this argument from their own review [2] in which they analysed five available studies comparing tenodesis or tenotomy in regard to elbow flexion strength. However, in three of the five included studies patients with concomitant rotator cuff repair were included serving as a huge bias because the influence of the rotator cuff tears must not be neglected. In the other two studies, the elbow flexion strength was only measured post-operatively, bringing no further information in terms of the preoperative status [1, 4–7]. None of those does allow any objective conclusions in regard to the elbow flexion strength in the treatment of long head of biceps pathology. Simultaneous rotator cuff repair must be considered as a major bias on the clinical scores and might also have an influence on elbow flexion strength by impairing shoulder function. Furthermore, one must keep in mind that rotator cuff repair was the leading pathology indicating shoulder surgery in those studies analysed.

Arthroscopic Autologous Chondrocyte Transplantation for Osteochondritis Dissecans of the Elbow

Osteochondritis dissecans of the humeral capitellum is characterized by separation of a circumscript area of the articular surface and the subchondral bone in juvenile patients. In advanced lesions, arthroscopic fragment refixation or fragment removal with microfracturing or drilling can be successful. The purpose of this technical note is to describe an all-arthroscopic surgical technique for 3-dimensional purely autologous chondrocyte transplantation for osteochondral lesions of the humeral capitellum.

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.

Ruptur der distalen Bizepssehne

Ein 52-jähriger Mann verspürt beim ruckartigen Anheben der ca. 40 kg schweren Batterieabdeckung seines Wohnmobils einen einschießenden Schmerz im rechten Ellenbogen mit plötzlichem Kraftverlust. Rasch zeigt sich eine Schwellung des distalen Oberarmes sowie ein Hämatom in der Ellenbeuge.

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.