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      Therapieentscheidung bei Kombinationspathologien Dysplasie – FAI – Fehlrotation : Wann und wieviel sollte korrigiert werden? How much should be corrected?

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          Zusammenfassung

          Hintergrund

          Dysplasie, FAI und femorale Fehlrotationen treten häufig gemeinsam auf und führen zu einem Mischbild an Symptomen und biomechanischen Einschränkungen der Hüfte.

          Fragestellung

          Was sind die aktuellen Empfehlungen zur bestmöglichen Diagnostik und Therapie bei Kombinationspathologien in der hüfterhaltenden Chirurgie.

          Methoden

          Auswertung und Diskussion der relevanten Literatur mit Berücksichtigung der eigenen Erfahrung in der Behandlung von komplexen kombinierten Pathomorphologien der Hüfte.

          Ergebnisse

          Die Anamnese und klinische Untersuchung sind richtungsweisend zur Bestimmung der für die Beschwerden ursächlichen Pathomorphologien. Ein korrekt zentriertes Beckenübersichtsbild sowie eine axiale Aufnahme der Hüfte ist die Grundlage der radiologischen Beurteilung der Hüfte, je nach Fall ergänzt mit MRT, CT sowie Animationen der Hüfte. Da sich die Pathologien funktionell gegenseitig beeinflussen, wird in der Behandlung ein schrittweises Vorgehen empfohlen mit vorerst Korrektur der funktionell relevantesten Pathologie, gefolgt von weiteren Korrekturen je nach Bedarf. Erreicht werden muss vornehmlich eine stabile, korrekt überdachte Hüfte, gefolgt von einem normalen Impingement-freien Bewegungsumfang und normalisierter Funktion der Muskulatur. Dabei ist bei der Wahl der Operationsmethode darauf zu achten, dass sämtliche Pathologien suffizient behandelt werden können.

          Schlussfolgerung

          Mittels der Operationstechniken der hüfterhaltenden Chirurgie können komplexe, kombinierte Pathologien der Hüfte suffizient behandelt werden. Wichtig ist eine gründliche Diagnostik, um die unterschiedlichen Pathologien und deren Zusammenspiel zu erkennen. Das Ziel der operativen Therapie ist eine möglichst korrekt überdachte, stabile Hüfte mit normalem Bewegungsumfang.

          Abstract

          Background

          Hip dysplasia, FAI and femoral malrotation often occur together, resulting in mixed symptoms and severe biomechanical limitations of the hip.

          Objectives

          To report on the current recommendations for the best possible diagnosis and treatment strategies of combination pathologies in hip-preserving surgery.

          Methods

          Review and discussion of the relevant literature with consideration of own experience in the treatment of complex combined pathomorphologies of the hip.

          Results

          Patient history and a thorough clinical examination are key for determining the predominant pathomorphologies causing the symptoms. Standardized conventional ap pelvic and axial images of the hip are the basis for the radiological assessment of the hip, supplemented with MRI, CT and animations of the hip, depending on the case. As the pathologies influence each other functionally, a stepwise approach to treatment is recommended. The functionally most relevant pathology is treated first, followed by further corrections as needed. The primary goal is to achieve a stable hip with normal acetabular coverage, followed by an impingement-free range of motion and normalized musculoskeletal function. Care must be taken in the choice of surgical method to ensure that all pathologies can be adequately treated.

          Conclusion

          Complex, combined pathologies of the hip can be treated sufficiently with hip-preserving surgery. A thorough diagnosis is important in order to recognize the functional interaction of the different pathologies. The goal of the surgical therapy is a correctly covered, stable hip with a normal range of motion.

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          Most cited references32

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          Femoroacetabular impingement: a cause for osteoarthritis of the hip.

          A multitude of factors including biochemical, genetic, and acquired abnormalities may contribute to osteoarthritis of the hip. Although the pathomechanism of degenerative process affecting the dysplastic hip is well understood, the exact pathogenesis for idiopathic osteoarthritis has not been established. Based on clinical experience, with more than 600 surgical dislocations of the hip, allowing in situ inspection of the damage pattern and the dynamic proof of its origin, we propose femoroacetabular impingement as a mechanism for the development of early osteoarthritis for most nondysplastic hips. The concept focuses more on motion than on axial loading of the hip. Distinct clinical, radiographic, and intraoperative parameters can be used to confirm the diagnosis of this entity with timely delivery of treatment. Surgical treatment of femoroacetabular impingement focuses on improving the clearance for hip motion and alleviation of femoral abutment against the acetabular rim. It is proposed that early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients.
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            Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip.

            Recently, femoroacetabular impingement has been recognised as a cause of early osteoarthritis. There are two mechanisms of impingement: 1) cam impingement caused by a non-spherical head and 2) pincer impingement caused by excessive acetabular cover. We hypothesised that both mechanisms result in different patterns of articular damage. Of 302 analysed hips only 26 had an isolated cam and 16 an isolated pincer impingement. Cam impingement caused damage to the anterosuperior acetabular cartilage with separation between the labrum and cartilage. During flexion, the cartilage was sheared off the bone by the non-spherical femoral head while the labrum remained untouched. In pincer impingement, the cartilage damage was located circumferentially and included only a narrow strip. During movement the labrum is crushed between the acetabular rim and the femoral neck causing degeneration and ossification. Both cam and pincer impingement lead to osteoarthritis of the hip. Labral damage indicates ongoing impingement and rarely occurs alone.
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              Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know.

              The purpose of this article is to show the important radiographic criteria that indicate the two types of femoroacetabular impingement: pincer and cam impingement. In addition, potential pitfalls in pelvic imaging concerning femoroacetabular impingement are shown. Femoroacetabular impingement is a major cause for early "primary" osteoarthritis of the hip. It can easily be recognized on conventional radiographs of the pelvis and the proximal femur.
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                Author and article information

                Journal
                Die Orthopädie
                Orthopädie
                Springer Science and Business Media LLC
                2731-7145
                2731-7153
                June 2022
                May 23 2022
                June 2022
                : 51
                : 6
                : 438-449
                Article
                10.1007/s00132-022-04252-7
                2257fdb3-4a72-42d2-acce-07170c7234cf
                © 2022

                https://creativecommons.org/licenses/by/4.0

                https://creativecommons.org/licenses/by/4.0

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