Akute Sprengung des Akromioklavikulargelenks

Dislocation of the acromioclavicular joint (AC joint) is a typical sports injury with rupture of the acromioclavicular and coracoclavicular ligaments which may result in a vertical and horizontal instability of the lateral clavicle. Stress X-rays may be of help for the diagnosis of vertical instability and for the diagnostics axial or Alexander views should be made. In the future magnetic resonance imaging (MRI) will play a significant role for the diagnostics of AC joint injuries. With this method injuries of ligaments, fascia and the glenohumeral joint can be diagnosed. There is controversy regarding the therapy of AC joint injuries. For slight injuries a conservative treatment is recommended, for medium degree instability there is too little evidence in the literature to give a clear recommendation whether conservative or operative treatment is superior and for severe instability an operative treatment is recommended. For operative treatment several techniques have been described. Some techniques have a high complication rate and implant removal is also disadvantageous. These disadvantages led to the development of minimally invasive or arthroscopic techniques. The first clinical results of these new techniques are encouraging.     

Ultrasound diagnosis of the acromioclavicular joint

Although standardized sonographic techniques are available, the diagnostic capabilities of sonography in diseases and injuries of the acromioclavicular [AC] joint are not yet widely used. Nevertheless, standardized sonographic techniques are available for examining injuries and diseases of the AC joint. Analogous to X-ray techniques, the bony relations of the clavicle and the acromion can be displayed. Joint effusions and marginal alterations of the subchondral bone plate can be imaged. However, there is no reliable method to display the articular disc and the coracoclavicular ligaments. There is no reproducible method for displaying the articular disk. Tears of the deltoid and trapezius muscles and their common fascia are easily detectable in high-grade injuries of the AC joint. The differentiation between acjoint injuries, i.e. Rockwood II/Rockwood IV, is facilitated, which aids in therapeutic decision making. In combination with conventional X-ray examination, sonography of the AC joint can be used at low cost and is easy to learn.     

Epidemiologie, Anatomie, Biomechanik und Bildgebung von Akromioklavikulargelenkverletzungen

Current techniques of acromioclavicular (AC) joint repair primarily focus on the reconstruction of the coracoclavicular (CC) ligaments. However, it is not clear if this approach is sufficient to restore vertical as well as horizontal AC joint stability and kinematics. This review focuses on the epidemiology of AC joint injuries and the coincidence of intra-articular pathologies. Furthermore, the clinically relevant anatomy and the pathomechanism of AC joint instability are described. The biomechanical characteristics of current procedures as they have been revealed by in vitro investigations are summarized. As a basic result, neither selective repair of the CC ligaments nor selective repair of the AC ligaments could be shown to restore both vertical and horizontal joint stability. Similar to the intact ligaments CC repair primarily provides vertical joint stability while AC repair is able to restore horizontal stability. In conclusion a biomechanically effective treatment of AC joint separation should analyze the individual instability pattern in the first step. Therefore, the radiological standard according to Rockwood should be supplemented by specific stress x-rays for quantification of dynamic horizontal AC joint instability. In the second step an adequate surgical treatment considering CC and AC stabilization should be performed meeting the individual patient requirements.     

臭氧与曲安奈德治疗膝关节半月板损伤的病例对照研究

目的：比较曲安奈德、臭氧以及两者联合治疗轻型半月板损伤的临床疗效.方法：2008年1月至2012年12月将MRI诊断为Ⅰ、Ⅱ级的半月板损伤患者119例,分为曲安奈德组、臭氧组和曲安奈德加臭氧联合组.曲安奈德组（A组）40例,男38例,女2例;年龄18～48岁,平均（25.34±6.34）岁;单膝36例,双膝4例;关节积液44膝.臭氧组（B组）39例,男37例,女2例;年龄19～50岁,平均（26.98±7.20）岁;单膝33例,双膝6例;关节积液40膝.曲安奈德加臭氧联合组（C组）40例,男37例,女3例;年龄18～47岁,平均（26.44±6.38）岁;单膝33例,双膝7例;关节积液39膝.3组分别以醋酸曲安奈德3 mg、浓度30 μg/ml的医用臭氧30 ml、两者联合行膝关节腔注射,每周1次,4次为1个疗程.治疗前与治疗后的1个月分别进行Lysholm膝关节功能评分和行MRI检查观察膝关节积液变化并比较.结果：3组治疗前后膝关节功能评分分别为A组：35.68±4.15和65.55±7.66;B组：36.35±6.83和74.39±8.47;C组：36.62±6.03和95.47±4.78.3组治疗后膝关节评分均高于治疗前,C组较A、B组评分高,而A、B组间差异无统计学意义.治疗前MRI检查所见关节积液征象的膝数,A组44膝,B组40膝,C组39膝;治疗后MRI检查所见关节积液征象的膝数,A组14膝,B组15膝,C组5膝.C组消除关节积液的效果优于A、B组,A组和B组间差异无统计学意义.结论：臭氧和曲安奈德治疗轻度半月板损伤对缓解症状、促进关节功能恢复、消退关节积液均有效果,两者联用,效果更佳.     

Erweiterte Diagnostik der Kapselbandverletzungen am Kniegelenk

X-rays taken under mechanical positioning of the joint with standardized conditions are helpful aids in the diagnosis of injuries of the knee capsule and ligaments. In comparison to the non-affected knee the extent of instability of the joint can be exactly demonstrated. Arthrography is of little help in fresh injuries to the knee capsule and ligaments, but can be useful to assess the residuals of old damage to the joint. Arthroscopy has its place mainly in the diagnosis of old injuries and hardly any in fresh lesions. In general, however, arthroscopy is a very valuable diagnostic procedure.     

Stabilization of pelvic fractures]

In contrast to less complicated injuries to the pelvic ring, unstable bony fractures and injuries caused to ligaments by high-energy trauma require immediate stabilization by internal fixation. Since patients with severe pelvic injuries commonly present with multiple trauma, close cooperation between different medical disciplines is necessary to provide for optimum patient management. In cases with concomitant urological injuries, a joint primary intervention is recommended. Whether anterior, posterior or combined approaches are indicated for internal fixation depends on the injury pattern. The classification of pelvic ring fractures into group A, B and C injuries is discussed in detail.     

兔肘关节尺侧副韧带急性损伤手术与非手术治疗后负载和强度的比较

目的 比较兔急性肘关节尺侧副韧带损伤后手术修复与非手术治疗的差异.方法 新西兰兔81只按随机数学表法分为三组(n=27),正常对照组(A组):暴露右尺侧副韧带后,但不切断;韧带缝合组(B组):切断右尺侧副韧带后随即缝合韧带;韧带不缝合组(C组):切断右尺侧副韧带后不缝合.分别于术后3、6、12周三个阶段取材,进行生物力学检测.结果 术后12周B组断裂时的最大载荷[(68.23±5.64)N]与C组[(42.45±3.66)N]比较,差异有统计学意义(P<0.05);B组与A组[(72.86±2.99)N]比较,差异无统计学意义(P>0.05).B组应力强度[(3.84±0.47)N/mm2]与C组[(2.84±0.17)N/mm2]比较,差异有统计学意义(P<0.05);B组与A组[(4.09±0.15)N/mm2]比较,差异尤统计学意义(P>0.05).结论 肘关节尺侧副韧带急性损伤后手术治疗明显优于非手术治疗.     

Anatomie der akromiokorakoklavikulären Region

Background

The acromioclavicular (AC) joint connects the acromion with the lateral end of the clavicle and constitutes an important load-transmitting element between the upper extremity and the skeleton of the trunk.

Aim

This review discusses functional aspects that relate the AC and the coracoclavicular (CC) ligaments to AC joint instability and lateral clavicle fracture.

Results

In terms of stability the AC and CC ligaments play a pivotal role for this region. Under normal conditions the restraint system is balanced and becomes unbalanced in cases of injury such as AC joint instability or lateral clavicular fractures. Skeletal injuries frequently affect the ligaments with their usually sharp-angled insertion sites, which alters the function of the restraint system. As a consequence these injuries lead to multidirectional dislocating forces acting on the scapula in relationship to the lateral end of the clavicle. Previously, special attention was given to the vertical dislocation of the lateral clavicle, whereas less attention was paid to other factors which could lead to dislocation in other directions. Therefore, in this review emphasis is placed on the anatomical principles of multidirectional dislocation of the AC joint the fractured lateral clavicle.

Conclusion

Current clinical classification schemes fail to sufficiently include these multidirectional dislocating forces; however, they have to be considered when choosing the appropriate treatment modality. Thus, understanding the anatomical and functional context of the AC/CC region is essential for a sound management of AC joint injuries and fractures of the distal clavicle.

     

Stable ankle joint fractures. Indications for operative or conservative treatment?

In German literature, ankle joint fractures are mostly classified in three groups according to Weber. In cases of the type A, the fracture line runs below, in cases of type B at height of the syndesmotic ligaments. C-type fractures are typically seen above this region. However, this practical and simple classification allows no inferences at accompanying injuries which in turn influence the functional outcome. We observed isolated fractures of the lateral malleolus in more than 60% of all type B-fractures, as soon as in the majority the type A-fractures. Since isolated medial ankle fractures occur very rarely, careful exclusion of further injuries is advisable here. In order to differentiate stable ones from unstable type B ankle injuries, we carry out a manual stress test, if there is less than 2 mm fracture dislocation and a congruent ankle mortise. In this manner we could find that stable lateral ankle fractures are characterized with a combination of an intact dorsal syndesmotic and medial ligament. Stable type B and undisplaced type A fractures were treated conservatively with an ankle brace (Aircast?). Unstable ankle injuries were treated by ORIF. Conservative treatment for undisplaced medial malleolar fractures is recommended, if x-rays showed less than 2 mm dislocation which allows a tibio-talare impingement. Biomechanical investigations could prove a significant increase in ankle joint stability, when an axial load of 300 N was applied to various horizontal loads. The talus does not follow automatically a displaced fibular fracture. The dorsal syndesmotic and the medial deltoid ligaments control ankle joint stability.     

Biomechanical Comparison of an Intramedullary and Extramedullary Free-Tissue Graft Reconstruction of the Acromioclavicular Joint Complex

Background

Several different surgical techniques have been described to address the coracoclavicular (CC) ligaments in acromioclavicular (AC) joint injuries. However, very few techniques focus on reconstructing the AC ligaments, despite its importance in providing stability. The purpose of our study was to compare the biomechanical properties of two free-tissue graft techniques that reconstruct both the AC and CC ligaments in cadaveric shoulders, one with an extramedullary AC reconstruction and the other with an intramedullary AC reconstruction. We hypothesized intramedullary AC reconstruction will provide greater anteroposterior translational stability and improved load to failure characteristics than an extramedullary technique.

Methods

Six matched cadaveric shoulders underwent translational testing at 10 N and 15 N in the anteroposterior and superoinferior directions, under AC joint compression loads of 10 N, 20 N, and 30 N. After the AC and CC ligaments were transected, one of the specimens was randomly assigned the intramedullary free-tissue graft reconstruction while its matched pair received the extramedullary graft reconstruction. Both reconstructed specimens then underwent repeat translational testing, followed by load to failure testing, via superior clavicle distraction, at a rate of 50 mm/min.

Results

Intramedullary reconstruction provided significantly greater translational stability in the anteroposterior direction than the extramedullary technique for four of six loading conditions (p < 0.05). There were no significant differences in translational stability in the superoinferior direction for any loading condition. The intramedullary reconstructed specimens demonstrated improved load to failure characteristics with the intramedullary reconstruction having a lower deformation at yield and a higher ultimate load than the extramedullary reconstruction (p < 0.05).

Conclusions

Intramedullary reconstruction of the AC joint provides greater stability in the anteroposterior direction and improved load to failure characteristics than an extramedullary technique. Reconstruction of the injured AC joint with an intramedullary free tissue graft may provide greater strength and stability than other currently used techniques, allowing patients to have improved clinical outcomes.     

双束Endobutton解剖重建喙锁韧带治疗肩锁关节脱位的早期随访研究

目的观察解剖重建喙锁韧带治疗Rockwood Ⅲ及以上肩锁关节脱位的临床疗效。 方法选取22例肩锁关节脱位患者,其中男15例、女7例,新鲜脱位16例,陈旧性脱位6例,Rockwood Ⅲ型7例、Ⅳ型1例、V型14例。手术方式选择为双束Endobutton解剖重建技术。分别于术后3、6和12个月行疼痛视觉模拟评分及Constant肩关节功能评分,摄双侧肩关节正位X线片,测量患侧及健侧喙锁间距。 结果此研究平均随访时间为（17.7±4.0）个月。疼痛视觉模拟评分从术前的平均5.0分下降到术后12个月的0.2分,Constant肩关节功能评分从术前的平均44.3分提高到术后12个月的93.7分。患侧喙锁间距从术前的平均21.0 mm下降到术后12个月的8.5 mm。所有病例随访过程中均无肩锁关节再脱位、锁骨喙突骨折等严重并发症发生。 结论双束Endobutton解剖重建喙锁韧带是安全可靠的新术式,其应用于Rockwood Ⅲ-V型新鲜或者陈旧性肩锁关节脱位的手术治疗取得了良好的临床效果。     

Ligamentäre Ausheilungsergebnisse nach Beckenringfrakturen Typ C

Background

Posterior pelvic ring fractures are often associated with injuries of lumbopelvic soft tissue structures. The aim of this prospective MR study was to examine whether ruptured iliolumbal ligaments could be diagnosed in types B and C pelvic ring fractures. The influence of triangular lumbopelvic stabilization (TLPS) was also investigated with respect to stiffening of the lumbopelvic region.

Material and methods

Using a 1.5 Tesla MRI, 20 patients with types B and C fractures were examined to identify ruptured iliolumbal ligaments. In a retrospective study of 30 patients previously stabilized with a TLPS, pain scores, clinical instability testing and measuring of the segmental dislocation in extension, flexion and lateral flexion based on x-rays were also investigated.

Results

Of the patients 3 (1 type B, 2 type C fractures) had incompletely ruptured iliolumbal ligaments. In five patients pain intensity and localization could be significantly correlated with clinical instability of the lumbopelvic region, segmental hypermobility and instability.

Conclusion

Pelvic ring fractures types B and C can be associated with ruptured iliolumbal ligaments. Lumbopelvic instability can be correlated with early implant loosening of TLPS.     

Surgical reconstruction of the acromioclavicular joint: Can we identify the optimal approach?

Injuries to the acromioclavicular (AC) joint are common, tending to occur secondary to traumatic injuries. Rockwood grade IV, V and VI injuries involve complete dislocation of the joint and require surgical reconstruction, with inconclusive literature on whether grade III injuries should be surgically or conservatively managed. There are over one hundred reported surgical techniques which reconstruct the AC joint, with little indication of which methods achieve the best results. Techniques can generally be considered as: anatomical reduction; CC ligament reconstruction; and anatomical reconstruction. Techniques which implant hardware to reduce the AC joint, such as the hook plate, are commonly implemented, but have been shown to alter the mechanics of the joint significantly, resulting in poor short-term and long-term outcomes. Methods which reconstruct both the acromioclavicular and coracoclavicular ligaments are comparatively new, and early reports suggest that they achieve biomechanical properties similar to the native joint. More focus should be placed on such techniques in the future to determine whether they offer a more suitable approach to improve patient outcomes following AC joint reconstruction.     

Arthroskopisch gestützte Techniken zur Versorgung der akuten und chronischen AC-Gelenk-Verletzung

Acute and chronic acromioclavicular (AC) joint dislocation is frequently encountered in the routine clinical practice. This injury can lead to significant impairment of shoulder girdle function. Therapy based on the severity of injury is recommended to re-establish correct shoulder function. The static radiographic Rockwood classification is used to define the degree of dislocation but the clinical aspects and functional x-ray imaging of horizontal AC joint instability should also be considered for selection of the appropriate procedure. Rockwood grades I and II injuries are treated non-operatively with early functional exercise. The approach for Rockwood grade III injuries should be individual and patient-specific, with non-surgical procedures for low functional requirement patients with a high risk for surgical interventions. For patients with high demands on shoulder function surgery is recommended. A detailed diagnostic assessment frequently reveals Rockwood grade III injuries to be type IV injuries. Rockwood types IV and V AC joint dislocations require surgery for sustained stability. Treatment of acute injuries is recommended within 1-3 weeks after trauma but there is no clear evidence of a cut-off for the presence of chronic injuries. Various surgical techniques have been described in the literature. This article presents an arthroscopically assisted technique that addresses both vertical and horizontal instability of the AC joint.     

Einteilung und klinische Diagnostik der Kapselbandverletzungen am Kniegelenk

A classification of lesions of the capsule and ligaments of the knee joint can be related to the possible dislocation of the tibial head due to the injury. Analysing the dislocation the injured structures can be determined. This classification provides a better planning for the reconstruction of fresh and old injuries. A proper knowledge of the anatomy and the biomechanics of the knee joint is essential. Experimental and clinical experience over the last decade show that a simple classification in lateral, medial, anterior and posterior instability is inadequate. Therefore a more specific classification is recommended. Under this aspect history and clinical findings are of utmost importance for the diagnosis of injuries to the capsule and the ligaments of the knee joint.     

新鲜Tossy Ⅲ型肩锁关节脱位内固定术中喙锁及肩锁韧带处理的病例对照研究

目的：探讨新鲜Tossy Ⅲ型肩锁关节脱位内固定术中喙锁、肩锁韧带的处理方法、并发症和疗效。方法：自2003年7月至2012年5月,对127例新鲜Tossy Ⅲ型肩锁关节脱位患者,采用锁骨与喙突间钢丝固定或锁骨钩状钢板固定术,根据术中是否修复喙锁、肩锁韧带分组。锁骨与喙突间钢丝固定组（A组）63例,修复喙锁、肩锁韧带,男39例,女24例;平均年龄（33.25±8.46）岁（17～59岁）.锁骨钩状钢板固定组（B组）64例,不修复喙锁、肩锁韧带,男41例,女23例;平均年龄（34.10±7.19）岁（19～57岁）.分别从手术时间、术中出血量、术后并发症发生率及疗效方面比较两组治疗效果。结果：根据Karlsson标准,A组63例,优54例,良9例,差0例;手术时间平均（55.90±26.56） min;术中平均出血量（99.80±50.30） ml;1例术后第16周发现钢丝断裂但无肩锁关节再脱位,3例出现切口脂肪液化,1例出现肩关节活动后疼痛,取出内置物后疼痛消失。B组64例,优52例,良12例,差0例;手术时间平均（49.50±23.14） min;术中平均出血量（87.30±46.41） ml;2例出现切口脂肪液化,2例出现肩关节活动后疼痛。全部患者4～9个月后取出内置钢丝或者锁骨钩状钢板,随访9～16个月,无肩锁关节再脱位。两组方法在平均手术时间、术中平均出血量和伤口脂肪液化、感染、肩部疼痛、内固定失效、肩锁关节再脱位等并发症发生率及疗效方面差异均无统计学意义。结论：新鲜TossyⅢ型肩锁关节脱位内固定术中采用锁骨与喙突间钢丝固定或锁骨钩状钢板固定是一种操作简单、创伤小、出血少、疗效确切的方法。术中不修复喙锁、肩锁韧带,不增加手术并发症发生率。     

The radiological Lachman test: an extremely exact and predictive method for the assessment of recent and old injuries to the cruciate ligaments

The object of this paper is to examine the efficiency of the Lachmantest in the evaluation of injuries to the cruciate ligaments. As our examinations show-100% correct results-this test gives high qualitative and quantitative evidence and furthermore complies with all the necessary demands required for a standardization of a method of measuring. The standardized X-ray-Lachman-test therefore not only shows any injuries to the cruciate ligaments in new and old injuries of the knee joint without anesthesia but is also suitable for a progress control after the restauration of the cruciate ligaments or plastic ligament surgery respectively.     

Biomechanik aktueller Rekonstruktionstechniken bei Schultereckgelenksprengungen

Current techniques for acromioclavicular (AC) joint repair primarily focus on the reconstruction of the coracoclavicular (CC) ligaments. However, it is unclear whether this approach is sufficient to restore vertical as well as horizontal AC joint stability and kinematics. Therefore, this review summarizes the biomechanical characteristics of current procedures as they have been revealed by in vitro investigations. As a basic result, neither selective repairs of the CC ligaments nor selective repairs of the AC ligaments could be shown to restore both vertical and horizontal joint stability. Similar to the intact ligaments, CC repair primarily provides vertical joint stability, while AC repair is able to restore horizontal stability. Thereby, the lack of horizontal stability of the CC repairs could not be compensated using tendon grafts, double-bundle techniques, and flip-button fixation. In conclusion, a biomechanical effective treatment of AC joint separation should analyze the individual instability pattern in the first step. In the second step, an adequate surgical treatment considering CC and AC stabilization should be performed meeting the individual demands.     

Geschlossene Kapsel-Band-Verletzungen des Daumengrundgelenkes — Diagnostik und Therapie

Zusammenfassung 7 frische und 9 veraltete Fälle mit vornehmlich ulnarer Kapsel-Band-Läsion des Daumengrundgelenkes werden bezüglich der Therapie und der Nachuntersuchungsergebnisse besprochen. Bei den veralteten Fällen konnte das operative Ergebnis bei 7 Patienten als sehr gut bis befriedigend eingestuft werden, lediglich 2 Fehlergebnisse waren zu verzeichnen. Diese Untersuchungsergebnisse wurden zum Anlaß genommen, erneut auf den Mechanismus und die Diagnostik der Bandruptur des Daumengrundgelenkes einzugehen, da die operative Primärversorgung frischer Bandrupturen erfolgreicher ist als der plastische Ersatz veralteter Bandschäden.

---

Closed injuries to capsular and ligamentous structures of MP I joint — Diagnosis and treatment

Summary 7 new and 9 old injuries of the MP I joint primarily involving the ulnar capsule and ligaments have been reevaluated for treatment and results. In old cases, the operative result could be classified as excellent and good in 7, while 2 were considered as failures. These results have been used to discuss the mechanism and diagnosis of ruptures of the MP I joint ligaments. Primary surgical treatment of fresh ligamentous injuries is far superior than plastic reconstruction of old injuries.

     

Posterolateral dislocation of the knee joints：analysis of 9 case

Objective:To analyze the rtraumatie pathologieal characteristics of posterolateral dislocation of knee joins and its treatment.Methods:Mine cases of posterolateral dislocation of knee joint,5 cases of fresh injuries(the fresh injury group)and 4 cases of old injuries (the old injury group)were reviewed and analyzed.In the fresh injury group 4 cases failed in close reduction due to “buttonholing”through the medial joint,among them 3 case underwent repair of the damaged ligantents.In the old injury group 2 cases underwant ACL and MCL repair only in acuts stage,but re-dislocated.Of the rest 2 case 1 was associated with peroneal nerve injury and the other was not treated of the tibiul condyle and popllteal artery injury.Open reduction was performed in 3 enses.One case was fixed with 2-crossed pin and another was fixed with one pin through the tibial and femoral condyle and second pin with olecranization fixation.Plester immobilization for 6.8 weeks respectively was required.In the old injury group in 1 case ACL and PCL repair(Augustine method) and posterolateral structure were performed and olecranization fixation and plaster immobilization for 6 weeks was needed.Arthrodesis of the knee was done for the patient with comminuted fracture of the tibial condyte and popliteal artery injury.Results:All the cases were followed up for 1-23 years(average 6 years).Knee stabllity in 4 cases with repair of the ligaments was improved,although PDT showed ( ) with different was improved,although the patients treated with ligamentous reconstruction were much better than those of the patients without any repair. Conclusions:Well understanding of the tranmatic pathological characteristics,repair of the damaged postoperative immobilization for 6 weeks are the key points of successful treatment.