Schulthess Clinic

Zürich, Switzerland

Schulthess Clinic

Zürich, Switzerland

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Zaltz I.,William Beaumont Hospital | Kelly B.T.,Hospital for Special Surgery | Larson C.M.,Minnesota Orthopedic Sports Medicine Institute | Leunig M.,Schulthess Clinic | Bedi A.,University of Michigan
Arthroscopy - Journal of Arthroscopic and Related Surgery | Year: 2014

The variety of hip pathology that can be addressed in a minimally invasive fashion in the young, pre-arthritic patient has rapidly grown in parallel with technical advances in hip arthroscopy. However, the indications and limits of arthroscopy must be carefully defined and indications must evolve correspondingly to avoid an increase in failure rates and unsatisfactory clinical outcomes. Some diagnoses may be better and more comprehensively addressed with open procedures or combined surgical approaches. The purpose of this article is to provide an unbiased and evidence-based review of conditions of the pre-arthritic hip to define our current understanding of the advantages, disadvantages, and limitations of an arthroscopic approach. © 2014 by the Arthroscopy Association of North America.


Ganz R.,University of Bern | Horowitz K.,Schulthess Clinic | Leunig M.,University of Bern
Clinical Orthopaedics and Related Research | Year: 2010

Background: Residual acetabular dysplasia of the hip in most patients can be corrected by periacetabular osteotomy. However, some patients have intraarticular abnormalities causing insufficient coverage, containment or congruency after periacetabular osteotomy, or extraarticular abnormalities that limit either acetabular correction or hip motion. For these patients, we believe an additional proximal femoral osteotomy can improve coverage, containment, congruency and/or motion. Purposes: We provide algorithms for (1) identifying patients we believe will benefit from proximal femoral osteotomy, (2) selecting the appropriate osteotomy, and (3) choosing the sequence of these osteotomies. Methods: Anteroposterior, false-profile and functional radiographs and MR can identify most patients we believe will benefit from periacetabular and femoral osteotomies. Recently described techniques, including relative femoral neck lengthening, femoral neck osteotomy and femoral head osteotomy have expanded indications for a combined procedure. Historically performed first, periacetabular osteotomy is now frequently performed following femoral osteotomy. Results: The rate of intertrochanteric osteotomy performed with periacetabular osteotomy has decreased from approximately 10% in the first 500 surgeries to about 2% currently. Among 151 relative neck lengthenings (23 with PAO), 53 femoral neck osteotomies (4 with PAO) and 14 femoral head osteotomies (11 with PAO), eleven complications occurred including osteonecrosis in two and delayed unions in eight. No complication occurred following a combined procedure. Conclusion: Although isolated periacetabular osteotomy can provide sufficient coverage, containment and congruency for most patients with residual hip dysplasia, some may benefit from an additional proximal femoral osteotomy. Knowing the appropriate indications, selection, and sequencing of these osteotomies is critical for enhancing patient outcomes. Level of Evidence: Level V, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. © 2010 The Association of Bone and Joint Surgeons®.


Liebert G.,Schulthess Clinic | Sutter R.,University of Zürich | Impellizzeri F.M.,Schulthess Clinic | Leunig M.,Schulthess Clinic
Clinical Orthopaedics and Related Research | Year: 2013

Background: Damage to the hip can occur due to impingement or instability caused by anatomic factors such as femoral and acetabular version, neck-shaft angle, alpha angle, and lateral center-edge angle (CEA). The associations between these anatomic factors and how often they occur in a painful hip are unclear but if unaddressed might explain failed hip preservation surgery. Questions/purposes: We determined (1) the influence of sex on the expression of impingement-related or instability-related factors, (2) the associations among these factors, and (3) how often both impingement and/or instability factors occur in the same hip. Methods: We retrospectively reviewed a cohort of 170 hips (145 patients) undergoing MR arthrography of the hip for any reason. We excluded 58 hips with high-grade dysplasia, Perthes' sequelae, previous surgery, or incomplete radiographic information, leaving 112 hips (96 patients). We measured femoral version and alpha angles on MR arthrograms. Acetabular anteversion, lateral CEA, and neck-shaft angle were measured on pelvic radiographs. Results: We observed a correlation between sex and alpha angle. Weak or no correlations were observed between the other five parameters. In 66% of hips, two or more (of five) impingement parameters, and in 51% of hips, two or more (of five) instability parameters were found. Conclusions: Patients with hip pain frequently have several anatomic factors potentially contributing to chondrolabral damage. To address pathologic hip loading due to impingement and/or instability, all of the anatomic influences should be known. As we found no associations between anatomic factors, we recommend an individualized assessment of each painful hip. Level of Evidence: Level III, prognostic study. See Instructions for Authors for a complete description of levels of evidence. © 2013 The Association of Bone and Joint Surgeons®.


Ganz R.,University of Bern | Leunig M.,Schulthess Clinic
Clinical Orthopaedics and Related Research | Year: 2013

Background: The most common location of labral tears and chondral damage in the hip is the anterosuperior region of the acetabulum, which is associated with pain in flexion and rotation. We describe a case series of patients with labral tears, ganglion formation, and chondromalacia isolated to the anteroinferior acetabulum. Clinically, patients had pain in extension and internal rotation. Case Descriptions: Isolated anteroinferior labral hypertrophy and ganglion were first observed in a patient with coxa valga. We retrospectively reviewed clinical and radiographic records and identified nine hips in seven patients with isolated anteroinferior damage. One patient with bilateral valgus femoral head tilt after slipped capital femoral epiphysis (SCFE) had impingement of the anteromedial metaphysis on the acetabulum from 3 to 6 o'clock. Five of seven had valgus neck-shaft angles and all had acetabular anteversion with damage isolated to the anteroinferior acetabular rim. Literature Review: Series on the diagnostic efficacy of MR arthrogram have noted anteroinferior damage adjacent to superior acetabular rim lesions. However, these do not describe isolated anteroinferior rim damage. In addition, available case series of patients with valgus SCFE do not describe a location of impingement or intraarticular damage. Purposes and Clinical Relevance: In this small case series of patients with isolated anteroinferior chondrolabral damage, there are two potential causative mechanisms: (1) primary anteroinferior impingement with femoral extension and internal rotation and (2) posterior extraarticular ischiotrochanteric impingement causing secondary anterior instability of the femur. The pathoanatomy appears to be multifactorial, necessitating an individualized treatment approach. © 2013 The Association of Bone and Joint Surgeons®.


Leunig M.,Schulthess Clinic | Leunig M.,University of Bern | Ganz R.,University of Bern
Bulletin of the NYU Hospital for Joint Diseases | Year: 2011

Intra-articular and extra-articular femoral Perthes deformities, or either, can result in severe alterations of the proximal femur and secondarily even involve the acetabulum, which can lead to premature osteoarthritis (OA) of the hip. In affected hips, joint damage due to impingement and instability may coexist. Classically, extraarticular impingement and associated abductor insufficiency in Perthes disease or similar pathologies are treated by trochanteric advancement. However, this leaves intraarticular impingement and instability unaddressed. The technique of surgical dislocation of the hip, in combination with a retinacular flap, allows for the relative lengthening of the femoral neck and even femoral head reduction osteotomy in such cases. This can be combined with an acetabular procedure to treat the secondary dysplasia. Since 2001, 14 patients with a minimum follow-up of 3 years have been treated by this technique without complications, such as femoral head osteonecrosis or trochanteric failures. All patients had markedly improved pain levels, hip mobility, and gait.


Zermatten P.,Schulthess Clinic | Munzinger U.,Schulthess Clinic
Acta Orthopaedica Belgica | Year: 2012

Unicompartmental knee arthroplasty (UKA) is being used increasingly. We report the outcome of a series of 48 Oxford II meniscal bearing UKAs carried out for osteoarthritis of the medial compartment (38 knees in 32 patients) and for spontaneous avascular necrosis of the medial femoral condyle (10 knees in 10 patients). Using the endpoint of revision for any cause, the outcome for every knee was established. Ten knees have been revised (20.8%). At ten years there were 21.5 knees still at risk and the cumulative survival rate was 77.7% (95% CI: 56.8 to 90.2). Our study reveals a higher failure rate than previous reports on this prosthesis. The technique of implantation of the Oxford knee is demanding; the learning curve is thus long and could explain, at least partially, our moderate results. © 2012, Acta Orthopædica Belgica.


Casartelli N.C.,Neuromuscular Research Laboratory | Leunig M.,Schulthess Clinic | Maffiuletti N.A.,Neuromuscular Research Laboratory | Bizzini M.,Neuromuscular Research Laboratory
British Journal of Sports Medicine | Year: 2015

Background: We aimed to appraise (1) the rate of return to sport of athletes after hip surgery for femoroacetabular impingement (FAI) and (2) some aspects that may influence the return to sport. Methods: Four databases (EMBASE, PubMed, Web of Science, Cochrane Library) were searched until 21 October 2014. Studies evaluated return to sport of athletes who underwent hip surgery for the treatment of symptomatic FAI. A validated tool was used for quality evaluation of the studies. Results: A total of 18 case series (level of evidence IV) with moderate-to-high methodological quality were included. On average, 87% of athletes returned to sport after hip surgery for FAI and 82% returned to the same sport level as before the occurrence of the symptoms. Professional athletes seem to return to sport at a higher rate compared with recreational and collegiate athletes. Sport participation after hip arthroscopy tends to decrease for professional athletes at short-term and mid-term follow-ups. Diffuse hip osteoarthritis at the time of surgery may not allow athletes to return to sport. Conclusions: Most athletes return to sport after hip surgery for the treatment of symptomatic FAI. The level of competition, time of evaluation after hip surgery and presence of articular cartilage lesions at the time of surgery may influence return to sport. Future studies with higher levels of evidence should describe and evaluate return to sport protocols after hip surgery for FAI. © 2015, BMJ Publishing Group. All rights reserved.


Naal F.D.,Ziegler | Impellizzeri F.M.,Schulthess Clinic
Clinical Orthopaedics and Related Research | Year: 2010

Background Qualitative research studies regarding physical activity in patients undergoing total joint arthroplasty (TJA) unfortunately are sparse in the current literature. Questions/Purposes To provide a foundation for future investigations, we performed a systematic review to identify the different instruments used to quantify physical activity in patients undergoing TJA and to determine how active these patients really are. Methods We systematically reviewed the literature on the bibliographic databases Medline, Cochrane Library, and EMBASE published until September 2008, focusing on studies assessing total physical activity in patients after or undergoing TJA. Results of those studies quantifying physical activity using accelerometers and pedometers were combined using meta-analytic methods. Results In the 26 studies included (n = 2460 patients), motion sensors and recall questionnaires were most commonly used. The research aims and goals varied widely among the studies and the results mainly were descriptive. Studies quantifying physical activity using pedometers and accelerometers suggested a weighted mean of 6721 steps/ day (95% confidence interval [CI], 5744-7698). Steps per day determined by accelerometers were 2.2 times the steps measured by pedometers. Metaregression showed that walking activity decreased by 90 steps/day (95% CI, -156 to -23) every year of patient age. Conclusions These results suggest patients undergoing TJA are less active than recommended to achieve health- enhancing activity levels (greater than 10,000 steps/day), but they appear more active than normally assumed in typical wear simulations. Future investigations have to evolve more standardization in the assessment and reporting of physical activity in TJA patients. © The Association of Bone and Joint Surgeons® 2009.


Naal F.D.,Foot and Ankle Center | Impellizzeri F.M.,Schulthess Clinic | Rippstein P.F.,Foot and Ankle Center
Clinical Orthopaedics and Related Research | Year: 2010

The number of studies reporting on outcomes after total ankle arthroplasty is continuously increasing. As the use of valid outcome measures represents the cornerstone for successful clinical research, we aimed to identify the most frequently used outcome instruments in ankle arthroplasty studies and to analyze the evidence to support their use in terms of different quality criteria. A systematic review of the literature identified 15 outcome instruments reported in 79 original studies. The most commonly used measures were the American Orthopaedic Foot and Ankle Society hindfoot score (n = 41), the Kofoed ankle score (n = 21), a visual analog scale assessing pain (n = 15), and the generic SF-36 (n = 6). Eight additional instruments were used only once or twice. The American Orthopaedic Foot and Ankle Society and Kofoed instruments include a clinical examination and score up to 100 points. Evidence to support their use in terms of validity, reliability, responsiveness, and interpretability is limited, raising the question whether their use is justified. Self-reported questionnaires related to ankle osteoarthritis or arthroplasty are rather disregarded in the current literature, and only the Foot Function Index is associated with evidence in terms of the above-mentioned quality criteria. Future research is warranted to improve the outcome assessment after total ankle arthroplasty. © 2009 The Association of Bone and Joint Surgeons®.


Mast N.H.,AONA Martin Allgower Fellowship | Impellizzeri F.,Schulthess Klinik | Keller S.,Schulthess Klinik | Leunig M.,Schulthess Clinic
Clinical Orthopaedics and Related Research | Year: 2011

Background: Several mechanical derangements reportedly contribute to the development of noninflammatory arthritis of the hip. Diagnosis of these derangements involves the use of specific radiographic measures (eg, alpha angle, lateral center edge angle, cross-over sign). The reliability of some of these measures is not known, whereas others have not been confirmed. Questions/purposes: We examined the reproducibility of 20 radiographic parameters of the hip used in clinical practice. Methods: Twenty radiographic parameters on standardized digital AP and cross-table lateral radiographs were evaluated by two observers on two different occasions. The parameters were evaluated from the standpoint of reproducibility (reliability and agreement). The intraclass correlation coefficient (ICC), kappa coefficient, and standard error of measurement were calculated. The minimal detectable change was calculated where possible. Results: Interrater reliability ranged from 0.45 to 0.90 for ICC depending on the measure. Intrarater reliability ranged from 0.55 to 0.99. Measurements that could be measured directly (femoral head diameter) were more reliable than measurements requiring estimation on the part of the observer (Tönnis angle, neck-shaft angle). Categorical parameters had interrater and intrarater reliability kappa values greater than 0.90 for all parameters measured. Agreement between repeated measurements, as given by the minimal detectable change, showed many parameters with low absolute reliability have clinical use in the context of the large changes seen in clinical practice. Conclusion: Radiographic hip measures show clinical utility when evaluated from the perspective of agreement and reliability. Clinical Relevance: All measures investigated show clinical utility when evaluated from the perspective of reliability and agreement. Level of Evidence: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence. © 2010 The Association of Bone and Joint Surgeons®.

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