Synoviale Erkrankungen und freie Gelenkkörper zählen zu den häufigsten Indikationen der Hüftarthroskopie. In der Literatur werden arthroskopische Operationen am Hüftgelenk bei freien Gelenkkörpern, verdickten Schleimhautfalten, der synovialen Chondromatose, der pigmentierten villonodulären Synovialitis (PVNS) sowie bei rheumatoider und septischer Arthritis beschrieben. Ein wesentlicher Vorteil der Arthroskopie gegenüber bildgebenden diagnostischen Verfahren besteht in der Möglichkeit zur einzeitigen Inspektion, Biopsie und chirurgischen Intervention. Im Vergleich zur Arthrotomie wird die ausgedehnte chirurgische Exploration, die mit einer höheren Morbidität und längerer Rehabilitation verbunden ist, vermieden. Dennoch ist ein kurativer Einsatz der Hüftarthroskopie nicht bei allen synovialen Erkrankungen möglich. Während bei freien Gelenkkörpern, Plicaeverdickungen, der septischen Arthritis im Frühstadium und mit Einschränkung bei der synovialen Chondromatose und lokalisierten PVNS eine kausale Therapie und eine Restitutio ad integrum erreicht werden können, ist die Indikation der Hüftarthroskopie bei der hochaktiven synovialen Chondromatose, der diffusen PVNS und der rheumatoiden Arthritis in der Diagnostik, der symptomatischen Therapie zur Reduzierung der Beschwerden und Erhalt bzw. Verbesserung der Gelenkfunktion und ggf. auch Vorbereitung für eine adjuvante, medikamentöse oder sekundär offene Behandlung zu sehen. Der Erfolg hängt maßgeblich von der richtigen Indikationsstellung und einer korrekten Operationstechnik ab.

Synovial disorders and loose bodies are one of the most common indications for hip arthroscopy. Arthroscopic intervention has been reported for loose bodies, synovial plicae, synovial chondromatosis, pigmented villonodular synovitis (PVNS) as well as rheumatoid and septic arthritis.One major advantage in comparison to radiologic imaging is the ability to inspect, biopsy, and treat within one procedure. In contrast to an arthrotomy, hip arthroscopy avoids the potential risks of extensive surgical exposure and prolonged rehabilitation. Nevertheless, hip arthroscopy cannot be promoted as curative in all synovial disorders. In patients with loose bodies, synovial plicae, initial septic arthritis and, to a certain extent, PVNS curative therapy and "restitutio ad integrum" can be achieved. In contrast, in patients with synovial chondromatosis and rheumatoid arthritis, the goal of hip arthroscopy is to enable the correct diagnosis and to provide symptomatic relief and maintain or improve joint function. Success or failure of arthroscopic treatment depends on proper patient selection and a correct arthroscopic technique.

Synoviale Erkrankungen und freie Gelenkkörper zählen zu den häufigsten Indikationen der Hüftarthroskopie. In der Literatur werden arthroskopische Operationen am Hüftgelenk bei freien Gelenkkörpern, synovialen Plicae, der synovialen Chondromatose, der pigmentierten villonodulären Synovialitis (PVNS) sowie bei rheumatoider und septischer Arthritis beschrieben.

Indikationen zu arthroskopischen Operationen am Hüftgelenk bestehen bei symptomatischen synovialen Plicae, der synovialen Chondromatose, der pigmentierten villonodulären Synovialitis (PVNS) und bei rheumatoider Arthritis. Ein erheblicher Vorteil gegenüber bildgebenden diagnostischen Verfahren besteht in der Möglichkeit zur einzeitigen Inspektion, Biopsie und chirurgischen Intervention. Im Vergleich zur Arthrotomie wird die ausgedehnte chirurgische Exploration, die mit einer höheren Morbidität und längerer Rehabilitation verbunden ist, vermieden. Dennoch ist ein kurativer Einsatz der Hüftarthroskopise nicht bei allen synovialen Erkrankungen möglich. Bei lokalen Synovitiden, hypertrophierten Plicae und mit Einschränkungen bei der PVNS können eine kausale Therapie und eine „restitutio ad integrum“ angestrebt werden. Die Indikation der Hüftarthroskopie bei der synovialen Chondromatose und rheumatoiden Arthritis ist in der Diagnostik und symptomatischen Therapie zur Reduzierung der Beschwerden und Verbesserung der Gelenkfunktion zu sehen. Der Erfolg hängt maßgeblich von der richtigen Indikationsstellung und einer korrekten Operationstechnik ab.

Ziel: Die Arthroskopie des peripheren Hüftkompartimentes ist noch wenig bekannt. Ziel der Arbeit war es, Indikationen und Technik dieses Verfahrens darzustellen.

Study Design. Retrospective radiographic evaluation of the sagittal alignment of the lumbar spine in patients undergoing short-segment instrumented posterior lumbar interbody fusion with cage systems of different shape.Objectives. To determine whether rectangular and wedge-shaped cages have a different influence on the sagittal alignment of the lumbar spine in patients undergoing short-segment instrumented posterior lumbar interbody fusion.Summary of Background Data. Previous studies of sagittal alignment after posterior lumbar interbody fusion have focused on the impact of intraoperative patient, hip, and knee positioning, as well as instrumentation characteristics on sagittal posture. The influence of the cage shape on indexes of total and segmental sagittal alignment of the lumbar spine is yet unknown.Methods. Forty-two patients having undergone instrumented short-segment posterior lumbar interbody fusion were reviewed retrospectively. Twenty-two patients ( 12 women and 10 men, 38 - 78 years of age) had posterior lumbar interbody fusion with rectangular cages. The fused segments were: 4 at L3 - L4, 16 at L4 - L5, 11 at L5 - S1. Thirteen patients had single- and nine patients double-level fusion. Twenty patients ( 8 women and 12 men, 34 - 81 years of age) had posterior lumbar interbody fusion with wedge-shaped cages. The fused segments were: 4 at L3 - L4, 15 at L4 - L5, 11 at L5 - S1. Ten patients had single- and 10 patients double-level fusion. Cages were packed with cancellous bone from the posterior iliac crest and/or bone fragments harvested by laminectomy. All patients had additional pedicle screw fixation. Pre- and postoperative standing lateral radiographs were assessed for segmental and lumbar lordosis as well lumbar and sacral tilt. Data were analyzed with repeated measures analysis of variance.Results. The mean follow-up period was 18 months with a minimum follow-up period of 14 months. Mean segmental lordosis of the fused segments showed significant changes between the two implant groups ( P < 0.05). Segmental lordosis decreased in the rectangular cage group from 10 degrees to 2 degrees at L3 - L4, from 10 degrees to 5 degrees at L4 - L5, and from 9 degrees before to 6 degrees after fusion surgery at L5 - S1. In the wedge-shaped cage group, segmental lordosis increased from 4 degrees to 7 degrees at L3 - L4, from 2 degrees to 8 degrees at L4 - L5, and from 9 degrees to 17 degrees at L5 - S1. Analysis of changes in lumbar lordosis and lumbar and sacral tilt did not show significant differences though opposite trends: lumbar lordosis decreased from 55 degrees to 48 degrees in the rectangular cage group and increased from 45 degrees to 53 degrees in the wedge-shaped cage group. Lumbar tilt measured 98 degrees before and 102 degrees after surgery in the rectangular cage group and 97 degrees before and 94 degrees after surgery. Sacral tilt measured 44 degrees before and 40 degrees after surgery in the rectangular cage group and measured 42 degrees before and 45 degrees after surgery in the wedge-shaped cage group.Conclusions. The cage geometry has a significant impact on the alignment of the lumbar spine after instrumented posterior lumbar interbody fusion. With rectangular cages, lumbar lordosis and segmental lordosis of the segments fused decrease; sagittal balance is maintained by compensatory changes of the sacral tilt. Wedge-shaped cages significantly increase segmental lordosis, enhance lumbar lordosis, and therefore should be preferred for restoring sagittal alignment in instrumented posterior lumbar interbody fusion procedures.

Einleitung: Ziel der Studie war die Bestimmung verschiedener Indizes des lumbalen Alignments nach instrumentierter, polysegmentaler dorsaler Spondylodese (PLIF) in Abhängigkeit von der Geometrie des intersomatischen Implantates.

Purpose: To quantify the effects of traction alone and in combination with distension of air in different joint positions in order to find out the conditions for adequate distraction of the hip joint with minimal traction force. Type of Study: Experimental cadaver study. Methods: Eight cadaver hip joints were studied. The cadavers were placed supine on a fracture table and traction was applied in different joint positions for flexion and abduction with and without distension using air. For the measurement, the joint space between the acetabulum and femoral head was separated by 4 different lines characterizing the lateral margin of the acetabulum, the superior portions of the lunate cartilage, and the acetabular fossa. Results: At all measurement lines, distraction of the hip was significantly better when traction and distension were combined. At traction forces from 250 to 300 N, traction plus distension resulted in a 1.59- to 2.25-fold increase of joint distraction compared to traction alone. The maximum effect of distension was achieved between 200 and 250 N. Up to traction forces of 250 N, the joint vacuum force counted for more than half of the total resistance. The effects of flexion and abduction on distraction of the hip were smaller. A trend for better distraction was found for 20degrees of flexion and a significantly better distraction by avoiding abduction. Conclusions: High traction forces by breakage of the joint seal can be avoided by distension using air. The passive resistance of the soft tissues increases at higher traction forces. Slight flexion without abduction showed further increase of joint distraction. Reducing the amount of traction may possibly reduce the risk of soft tissue perineal and neurologic injuries.

Blood loss is associated with any surgical procedure and should be reduced wherever possible. It was our impression that notchplasty adds to the amount of postoperative bleeding after anterior cruciate ligament (ACL) reconstruction. With posterior placement of the tibial tunnel, notchplasty is optional in many cases. This study aimed to quantify blood loss with and without notchplasty after arthroscopically assisted ACL reconstruction using bone-patellar tendon-bone autografts. We performed a prospective clinical study of 58 patients, who had undergone arthroscopically assisted autogenous patellar tendon ACL reconstruction. In group I, a notchplasty was necessary according to the local anatomical criteria (intraoperative impingement test). In group II, ACL replacement could be performed without notchplasty. Single and total day drainage volume, serum and suction drain hemoglobin (Hb) and hematocrit (Hct) levels were monitored. One year after surgery, the patients were reviewed to assess the outcome according to the IKDC and Lysholm scores and the KT-1000 arthrometer. The total drainage volume was 448 ml (range 150–550 ml) in group I and 299 ml (range 50–420 ml) in group II (p < 0.001). The serum hematocrit (Hct) decrease was 9.7% in group I and 7.4% in group II (p < 0.001). At 12 months after surgery, the IKDC and Lysholm score evaluations and the KT-1000 arthrometer measurements revealed no clinical differences between the notchplasty and non-notchplasty groups. Despite a 30% increase in blood loss, notchplasty has been shown to be a useful procedure to prevent graft impingement without negative side-effects.

PURPOSETo describe the in vivo anatomy of the peripheral compartment of the hip joint using a systematic sequence of examination without traction.TYPE OF STUDYCase series.METHODSWe performed 35 hip arthroscopies without traction from an anterolateral portal in the supine position. Free draping and a good range of movement of the hip joint were used to relax parts of the capsule and increase the intra-articular volume of the area that was inspected. Each procedure was documented on a standard protocol including detailed information on technical features and normal and pathologic intra-articular findings.RESULTSA comprehensive inspection of the peripheral compartment was obtained from the anterolateral portal. A systematic sequence of examination was developed separating the periphery of the hip joint into 7 areas: anterior neck area, medial neck area, medial head area, anterior head area, lateral head area, lateral neck area, and posterior area. The arthroscopic in vivo anatomy of each area is described. In 3 patients, 1 to 3 loose bodies were removed. In 1 patient with a synovial chondromatosis, 40 chondromas were retrieved. In osteoarthritis, impinging osteophytes were trimmed in 3 cases and partial synovectomy was performed in 10 patients. The following complications were observed: a temporary sensory deficit of the lateral femoral cutaneus nerve in 1 patient, scuffing of the anterior surface of the femoral head in 3 patients, detaching of an osteophyte in 1 patient, and partial tears of the anterior synovial fold in 10 patients.CONCLUSIONSArthroscopy without traction allows for a complete evaluation of hip anatomy without the loaded articular surfaces, the acetabular fossa, and the ligamentum teres. For a complete overview of both the central and peripheral part of the hip, traction is necessary for the central part.

The Fulkerson osteotomy has proved to be a reliable treatment for subluxation of the patella due to malalignment. Aggressive rehabilitation in the early postoperative period is unwise since the proximal tibia is weakened by the oblique osteotomy. Early weight-bearing and unrestricted activity have caused fractures in a few patients. Even late in the postoperative period the osteotomy may adversely influence the biomechanical properties of the proximal tibia. We describe two athletes who sustained a fracture of the proximal tibia, during recreational activities, six months after a Fulkerson osteotomy. Both had been bearing full weight for about ten weeks without complaint. Bony healing of the osteotomy had been demonstrated on plain radiographs at ten and at 12 weeks. After a Fulkerson osteotomy, jogging and activities which impose considerable impact force should be discouraged for at least nine to 12 months.

Der primäre Oberflächenersatz des Kniegelenkes ist ein weitgehend standardisierter Eingriff mit sehr guten Resultaten. Mit dieser Studie sollte die Frage beantwortet werden, wie hoch die Rate der Frührevisionseingriffe nach primärem Oberflächenersatz in unserem Krankengut war und welche Indikationen zugrunde lagen. Als „früh“ wurde nach rein zeitlichen Kriterien das erste postoperative Jahr definiert und somit der Beobachtungszeitraum festgelegt. Trotz einer gewissen Willkür erscheint der Zeitraum von einem Jahr nach der Operation „früh“im Vergleich zu dem, was Patient und Operateur an Standzeit der Prothese erwarten. Dabei wurde in Kauf genommen, dass die Eingrenzung des Begriffs „früh“im Zusammenhang mit einer postoperativen Infektion deutlich abweicht. Häufig wird nach rein zeitlichen Kriterien ein Frühinfekt von einem Spätinfekt unterschieden. Es existiert jedoch keine einheitliche Definition. Im Bemühen therapierelevante Einteilungen vorzunehmen, sehen manche Autoren lediglich eine Infektion innerhalb der ersten 4 postoperativen Wochen als Frühinfekt an, da nach ihrer klinischen Erfahrung nur in diesen Fällen ein Erhalt des Primärimplantates erfolgreich sein kann (Hartman et al. 1991, Mont et al. 1997, Segawa et al. 1999). Ritter und Esterhai (1995) unterteilen nach rein zeitlichen Gesichtspunkten in akut (bis 12 Wochen), subakut (12–52 Wochen) und spät (> 1 Jahr).

Ziel war die Evaluierung der Auswirkungen von Armierungskanälen in Knochenblöcken auf die Primärstabilität des BPTB-Transplantates. Die mechanischen Testung erfolgte an 30 Schweinepräparaten. Drei verschiedene Gruppen wurden getestet: 1. Zwei Armierungskanäle mit einem Durchmesser von 2,0 mm mit Verlauf in der Sagitalebene; 2. zwei Armierungskanäle mit gleichem Durchmesser mit Verlauf in der Frontalebene; 3. keine Armierungskanäle. Die signifikant höchste Ausreißfestigkeit wies die Gruppe ohne Armierungskanäle auf (875N ± 178N). Die Gruppe mit in der Sagittalebene gebohrten Armierungskanälen wies die geringste Ausreißfestigkeit auf (413N ± 174N). Der Blockbruch durch einen Armierungskanal war der häufigste Versagensmodus in den Gruppen 1 und 2 (je 7/10). Diese Ergebnisse lassen den Schluss zu, dass die üblicherweise im Verlauf der Sagittalebene (kortikospongiös) gebohrten Armierungskanäle Schwachstellen darstellen, die die Primärstabilität der Transplantatfixation im Vergleich zu anderen Anordnungen der Armierungskanäle signifikant senken.

Failure to conservative treatment in patients with less advanced radiographic signs of osteoarthritis of the hip (Danielsson grade 2-5) confronts with the decision of further treatment. Since radiographic imaging has not been proved very useful in demonstrating intraarticular structures and results of hip arthroscopies have been promising, arthroscopies have been performed in 17 hips from November 1997 to September 1998. Arthroscopic findings were exceeding preoperative imaging. In addition to cartilage degeneration, concomitant loose bodies, impinging osteophytes, degeneration of the labrum and synovial disease were found. Removal of loose bodies and osteophytes, partial resection of labral tears and partial synovectomy were performed. 1 month after arthroscopy (n = 15), mean Harris-Hip-Score was increased by 13 points und pain reduced by 39 % on average. 6 months after arthroscopy (n = 9), mean Harris-Hip-Score was increased by 14 points and pain reduced by 32 % on average. In addition to its therapeutic benefit, arthroscopy offers direct visualisation of the hip providing important information for the decision of further treatment.