Behandlung des kindlichen eitrigen Hüftgelenkinfektes durch arthroskopische Spülungen

Zusammenfassung Von den seltenen septischen Arthritiden im Wachstumsalter ist die eitrige Koxitis am häufigsten. Die notfallmäßige Differenzierung zur transienten Synovitis (Coxitis fugax) und die durchgeführte Therapie sind prognostisch entscheidend für das Resultat. Offene Hüftgelenksrevisionen mit Spülung und Einlegen einer Drainage sind invasiv und können für Kinder und Eltern traumatisierend verlaufen. Bei Erwachsenen ist die minimal-invasive arthroskopische Spülbehandlung bei Gelenkinfekten bereits etabliert, bei Kindern hingegen an der Hüfte noch nicht verbreitet. Wir behandelten von 1996-2001 9 Kinder im Alter zwischen 3 Monaten und 14 Jahren (Durchschnitt 8 9/12 Jahre) nach diesem Verfahren. Alle Patienten zeigten deutliche klinische sowie laborchemische Zeichen einer septischen Koxitis sowie sonographisch einen Hüftgelenkerguss, sodass die notfallmäßige arthroskopische Spülbehandlung erfolgte. Unmittelbar postoperativ wurde eine intravenöse Breitspektrumantibiose initiiert, welche nach bakteriologischer Aufarbeitung des Gelenkpunktates entsprechend der Resistenzprüfung umgestellt wurde. Die Kinder wurden gemäß den Beschwerden sofort mobilisiert. In 4 der 9 Fälle musste eine 2. arthroskopische Spülung bei sonographisch nachgewiesenem erneutem Auftreten des Hüftgelenksergusses sowie fehlender Normalisierung der Infektparameter durchgeführt werden. Zwei dieser Kinder zeigten eine Begleitosteomyelitis im metaphysären Bereich ohne Abszedierung oder Sequesterbildung. Drei bis 4 Wochen nach dem Eingriff waren die Kinder bereits wieder in ambulanter Behandlung, selbstständig mobil und zeigten unauffällige Laborparameter. Nach abgeschlossener Antibiose erfolgten halbjährliche Verlaufskontrollen, die bei allen Kindern unauffällige Infektparameter sowie Beschwerdefreiheit zeigten. Auch die 2 Kinder mit Begleitosteomyelitis wiesen ohne weitere Intervention einen problemlosen klinischen und radiologischen Verlauf auf. Die arthroskopische Spülbehandlung, begleitet von einer resistenzgerechten Antibiose, ist eine adäquate und minimal-invasive Behandlungsmethode der eitrigen Koxitis im Kindesalter. Das Verfahren bietet sich bei den Hüftgelenkinfekten der Stadien I-III (Einteilung nach Stutz und Gächter) an und lässt sich auch bei Säuglingen durchführen. Die Behandlung zeigt die gleiche Effektivität wie die offene Gelenkrevision bei kürzerer schmerzbedingter Immobilisation sowie kleinerer Invasivität. Abstract Introduction. Septic arthritis is rare during growth. The hip is the most frequent affected joint. Early diagnosis by differentiation against transient synovitis (coxitis fugax) followed by immediate irrigation of the joint is decisive for the prognosis. Arthrotomy, irrigation and drainage can be traumatizing for patients and parents. In adults arthroscopic treatment for septic arthritis of the knee-, ankle-, shoulder- and elbow-joint is well established. However, in children this minimal-invasive approach has not been widely used yet. Material and method. From 1996 to 2001 we treated 9 children (3 months to 14 years, average 8 9/12 years) with septic arthritis of the hip by arthroscopic irrigation. All patients showed clinical, sonographic and laboratory evidence for septic arthritis. Broad spectrum iv antibiotics were administered as soon as samples of joint fluid had been collected at the beginning of the procedure. Antibiotic treatment was modified according to the bacterias and their resistance. All patients were mobilized early with weight-bearing according to their pain. Results. In 4 patients a re-arthroscopy had to be performed based on sonographic re-occurrence of joint fluid and persisting high C-reactive protein. Two of those 4 children had a metaphyseal osteomyelitis without abscess formation or sequestration. After 3-4 weeks of hospitalisation and at halfyearly follow-up's all patients showed normal laboratory findings, were free of symptoms, had a full range of motion of the affected hip and were fully weightbearing. Conclusion. Arthroscopic irrigation followed by i.v. and oral antibiotic treatment proved to be an adequate alternative to open surgery for septic arthritis of the hip during growth. This minimal invasive approach offers better cosmesis, early mobilization and therefore a potentially shorter time for rehabilitation.     

Vordere Kreuzbandplastik

Ohne Zusammenfassung     

Probleme bei vorderer Kreuzbandplastik

Bungee effect, bone tunnel expansion and impingement are the main problems complicating reconstruction of the anterior cruciate ligament. Key points for anatomical reconstruction are graft and bone tunnel placement and graft fixation. Using bone-tendon-bone patellar ligament grafts, the press-fit technique has proven to be a useful alternative technique, achieving high primary stability with refilling of the tibial bone tunnel, avoiding postoperative bone tunnel enlargement and addressing the requirements of graft fixation at the anatomical points on the femoral and tibial sites. Fixation of hamstring tendon grafts is subject to the same principles of anatomical repair; particularly important are shortening the free graft length, reducing the elasticity of the construct, increasing the stiffness and avoiding the movements of the graft in the bone tunnel. Using hybrid fixation techniques prevents graft slipping and bone tunnel widening. Graft impingement should be avoided with intraoperative controls of K-wire placement before drilling the tibial bone tunnel.     

Nachbehandlung der vorderen Kreuzbandplastik

Most surgeons agree that postoperative rehabilitation is an important part of the final outcome after anterior cruciate ligament (ACL) reconstruction. With the aim of a full return of knee function in terms of stability, strength, range of motion and neuromuscular control different methods of rehabilitation are performed in different phases of graft healing. A review of the literature of prospective and randomized studies revealed the following information for the rehabilitation after ACL reconstruction with a bone-patellar tendon-bone (BPTB) autograft: a brace is not required. Full weight bearing reduces anterior knee pain and has no negative effect. Neuromuscular electrical stimulation increases muscle strength and improves kinematics. Cold therapy has no positive effect. Early joint motion can avoid the negative effect of immobilization. The literature on rehabilitation after ACL reconstruction with hamstrings is not sufficient for a consensus opinion.     

Die arthroskopische Rotatorenmanschettenrekonstruktion

Ohne Zusammenfassung     

Vordere Kreuzbandplastik: Langzeitprognose

Zusammenfassung Die Verletzung des vorderen Kreuzbandes mit anschließender Instabilität ist oft Ausgangspunkt degenerativer Veränderungen und Folgeschäden. Die operative Versorgung hat zum Ziel, eine physiologische Wiederherstellung des Kniegelenks zu erreichen, um Begleitschäden zu vermeiden. Während des letzten Jahrzehnts konnte sich die arthroskopisch assistierte vordere Kreuzbandplastik als eine reproduzierbare Methode etablieren, die auch langfristig zu guten Ergebnissen führt. Dabei wurden überwiegend die Patellarsehne und die Hamstringsehnen als autologer Ersatz gewählt. Beide Verfahren zeigen zumindest bei den mittelfristigen Resultaten keine signifikanten Unterschiede. Selbst langfristig kann mit der Rekonstruktion die Stabilität wiederhergestellt werden, es ist aber zu befürchten, dass die degenerativen Veränderungen fortschreiten. Es bleibt weiteren Studien vorbehalten die bestehenden Techniken kritisch zu untersuchen, um neue Therapien zu etablieren.     

Überlegungen zur Differentialindikation der vorderen Kreuzbandplastik

Ohne Zusammenfassung     

Massive Knochendestruktion nach vorderer Kreuzbandplastik

Fungal infections following arthroscopic reconstruction of the anterior cruciate ligament (ACL) are a very rare complication but several cases have been reported outside Europe. Patients are typically young immunocompetent patients with no comorbidities. In the case presented in this article an infection with Rhizopus microsporus was diagnosed. Imaging studies including magnetic resonance imaging (MRI) showed an extensive area of bone necrosis of the tibial plateau. Radical open débridement with massive resection of the tibial head and maximum dose antimycotic systemic therapy were required to stop the proliferation of the fungus.     

In-vivo-Kinematik des Kniegelenks nach vorderer Kreuzbandplastik

Ohne Zusammenfassung     

Arthroskopische Meniskusrefixierung vs. arthroskopische Meniskusteilresektion

The mid-term and long-term results of meniscus refixation (MRF) versus the meniscus partial resection (MPR) have not yet been compared directly regarding osteoarthritic changes. A total of 81 patients with an isolated meniscus rupture within a stable knee after arthroscopic meniscus-preserving surgery, were physically and radiologically examined, with 42 patients in the MRF group and 39 in the MPR group. Patients with bilateral knee injuries, previous surgery, additional chondral lesions, strong valgus and/or varus deviation and fatty degenerative meniscus lesions were excluded from the investigation. The osteoarthritic changes were radiologically estimated using the Fairbank score and compared to the other uninjured knee. Retrospectively all patients were reviewed and the time of follow-up was separated into mid-term (3.4 years) and long-term (8.9 years) after arthroscopic meniscus surgery. The success rate in the long-term follow-up was 95.24% for the MRF group and 94.87% for the MPR group. With respect to osteoarthritic changes, 81% showed no changes after MRF compared to 40% after MPR after 8.9 years. The MRF group showed a slightly lower incidence of osteoarthritic changes for the mid-term results after 3.4 years, but this was not statistically significant. Arthroscopic MRF for isolated meniscus tears in the vascular zone of the stable knee offers more favourable results regarding induction of osteoarthritis compared to partial meniscus resection with an identical risk of complications.     

Klinische Ergebnisse der ambulanten Rehabilitation nach vorderer Kreuzbandplastik

In contemporary arthroscopic reconstruction of the anterior cruciate ligament (ACL), essentially either the patellar tendon or the semitendinous tendon is chosen for grafts. The aim of the study performed at the Freiburg Rehabilitation Center South was to investigate whether there is a correlation between treatment results and various factors such as age, concomitant injury, surgical technique, surgical limitation of mobility, time lapse between operation and start of rehabilitation, or duration of outpatient rehabilitation. The clinical course after completion of outpatient rehabilitation was assessed in 185 cases. Early results were very good in 50%, good in 16%, satisfactory in 28%, and unsatisfactory in 6%. Advanced patient age and delayed initiation of rehabilitation were shown to be negative factors. Comparison of both surgical techniques (57% semitendinous tendon and 42% patellar tendon) revealed no statistically significant difference with regard to the overall positive early results. The duration of rehabilitation was slightly longer when the patellar tendon was used. Outpatient rehabilitation was remarkably well accepted. The costs were clearly below those expended for inpatient aftertreatment.     

Repetitive arthroskopische Revision zur Behandlung postarthroskopischer Kniegelenkinfekte

Introduction

Knee joint infection still cannot be completely prevented after an operation, especially arthroscopy. Arthroscopic rinse under systemic antibiotic treatment is the recommended therapy. The concept of “repeated arthroscopic revisions” is presented in this report.

Method

After diagnosing post-arthroscopic knee joint infection in the second or third stage according to Gächter, arthroscopy was performed in the infected knee joint repeatedly at defined intervals until the clinical, laboratory chemical, and arthroscopic signs of infection had faded and it was no longer possible to detect the germs microbiologically.

Results

In the 13 patients who had previously undergone arthroscopy for different indications, infection eased after 3–8 revisions (average 4.8), whereby open revisions were unnecessary. There was proof of germs in 61.5% of the cases, mainly of Staphylococcus aureus. CRP proved to be the essential laboratory parameter for observing the development, whereas the WBC count proved to be less reliable. After 6–18 months (average 12.5), no infection recurred. The follow-up results were similarly good in the Lysholm as well as the IKDC score.

Discussion

Although medical reports present us with high percentages of stage-dependent cures after only one arthroscopic revision, we recommend this concept of “repeated arthroscopic revisions” as a reliable, relapse-free method of healing.