Complex instability of the anterior knee

Complex knee instability involves the anterior cruciate ligament (ACL) and one or more major stabilizers of the knee [medial collateral ligament (MCL), lateral collateral ligament (LCL), posterior cruciate ligament (PCL)]. The medial side has a high healing potential and does not need operative treatment in most cases if ACL reconstruction is performed. Reconstruction of the medial ligament complex is indicated in gross instability of the medial meniscus fixation, dislocation of the MCL into the joint, and large dislocated bony avulsions. Injuries on the lateral side do not heal spontaneously and require acute operative treatment (first 2 weeks). Frank knee dislocations and gross multiligament injuries should be reduced acutely, and the integrity of the vascular structures must be examined closely. In a European multicenter study, operative treatment with reconstruction of both cruciate ligaments and functional rehabilitation gave better results than conservative treatment with immobilization of the joint.     

Compression arthrodesis of the knee joint]

The results of 42 cases of compression arthrodesis of the knee joint during a 5.5 years period are reviewed. Main indications were degenerative, rheumatoid and posttraumatic arthrosis and tuberculosis of the knee joint. Other differential indications and the operative procedure following the Charnley-Müller method are described. The complications - pseudarthrosis, infection, false rotation - are discussed.     

Usefulness of distraction osteogenesis in the treatment of knee arthrosis]

AIMS: The purpose of this study is the assessment of efficiency of distraction osteogenesis (DO) as a method of operative treatment of knee arthrosis with co-existent varus deformity. MATERIAL AND METHODS: Authors undertook an attempt of evaluation of results of tibial corticotomy in 21 patients (25 operated knee joints) treated in Orthopaedic Clinic of Wroclaw Medical University in years 1995-2001, with the use of circular, external Ilizarov's fixator. All the operated patients underwent corticotomy of proximal tibial metaphysis followed by slow axis correction and bone regenerate formation started at 7th postoperative day. In orthopaedic examination functional evaluation of knee joint with modified point scale according to Ranawat (HSS-score) there were taken into account. In rentgenometric examination the limbs axis in the frontal plane and joint space morphology according to Ahlback were evaluated. RESULTS: The results in our group of patients were very encouraging. Accordingly to Ranawat scale, in majority of patients assessed before the treatment as poor and fair moved to group assessed as fair and good and even excellent. We observed decelerated regenerate formation and remodeling probably caused by advanced age of patients in 6 cases. In 3 cases persistent lose of entire correction was observed. CONCLUSIONS: In author's opinion DO as a method of operative treatment of unicompartmental knee arthrosis could be advocated as alternative method to traditional tibial osteotomy considering its biological effect stimulating regeneration of all tissues including cartilage even in advanced unicompartmental arthrosis.     

Primary reconstruction of injuries of the capsular ligament of the knee joint

Whether operative or conservative treatment is indicated for acute knee ligament injuries depends on the lesions of the cruciate ligaments: complex instability with rupture of one or both cruciate ligaments and injuries to the lateral or medial ligamentous structures should be treated by operation. Surgical treatment of an isolated rupture of the anterior cruciate ligament is recommended only for the young active patient. Surgery is performed by way of a single anterolateral incision with standard medial and if necessary, lateral arthrotomies. Ruptures of the cruciate ligaments are reconstructed with absorbable sutures, which are passed through bone channels. Augmentation with an absorbable allograft is used in most reconstructions of the cruciate ligaments. A knee brace with limited range of motion is used for postoperative rehabilitation. Our long-term results after operative reconstruction of acute instabilities of the knee joint show that ligamentous stability was achieved in most cases, but the functional results were impaired by pain and limited range of motion.     

Proteoglycan fragments in joint fluid. Influence of arthrosis and inflammation.

We determined the concentration of proteoglycan fragments in knee joint fluid collected from knee-ligament injured patients more than 6 months after the trauma and from patients with acute pyrophosphate arthritis and arthrosis or with arthrosis only. Injured patients with normal or only mildly altered cartilage at arthroscopy and with normal radiographs, had twice the average concentration of healthy volunteers. Other injured patients with advanced, radiographic signs of arthrosis, had synovial fluid proteoglycan fragment concentrations within the range of healthy volunteers. Patients with pyrophosphate arthritis had the highest concentrations, substantially increased compared with both arthrosis patients, with or without knee injury and healthy volunteers. Likewise, there was an inverse relation between the degree of arthrosis and the concentration of proteoglycan fragments in the joint fluid in patients with pyrophosphate arthritis and arthrosis or with arthrosis only. We conclude that synovial fluid levels of proteoglycan fragments are influenced by the mass of cartilage matrix remaining in the joint, the inflammatory activity in the joint, and the metabolic activity of the cartilage cells.     

Gonarthrosis following persisting knee joint instability (author's transl)

It is frequently assumed that persisting instability of the knee joint leads to gonarthrosis. We have reviewed recent and primary radiograms of 32 patients with old knee trauma resulting in prolonged capsular and ligamentous instability in order to study the eventual development of secondary gonarthrosis. Our results were as follows: All primarily intact joints developed gonarthrosis after an average of 46 months of permanent instability. Primarily existing gonarthrosis increased with exception of 3 cases. The tendency to develop an arthrosis seems to be proportional to the duration of instability; the type of instability apparently has no influence on the development of an instability gonarthrosis. Operative procedures having been performed prior to final stabilysing surgery obviously do not cause the development of secondary gonarthrosis. The persisting instability of the knee joint after combined discontinuation of capsule and ligaments therefore may be regarded as a prearthrotic factor.     

High tibial osteotomy

High tibial osteotomy (HTO) is a widely performed procedure to treat medial knee arthrosis. In general, published studies on HTO report good long-term results with a correct patient selection and a precise surgical technique. The ideal candidate for an HTO is a middle aged patient (60 to 65 years of age), with isolated medial osteoarthritis, with good range of motion and without ligamentous instability. Some issues that need resolution remain; these include the choice between opening and closing wedge tibial osteotomy, the graft selection in opening wedge osteotomies, the type of fixation, the comparison with unicompartmental knee arthroplasty and whether HTO significantly affects a subsequent total joint replacement. Precise indication, preoperative planning, and operative technique selection are essential to achieve good results.     

Distraction biostimulation in the treatment of gonarthrosis]

There is described the method of operative treatment of gonarthrosis, ensuring prolonged trophic influence on the articulation by means of slow distraction of osseous transplants from the periarticular knee fragments with its simultaneous decompression at the Ilizarov's apparatus. Prolonged (3 and more months) process of osseous reparation in the immediate proximity of knee joint with simultaneous unloading of articulation cartilage creates better conditions for involutional development of arthrosis with significant decrease of pain syndrome for 20 months, that has been noted with all patients.     

同侧下肢长骨骨折并急性膝关节不稳定的治疗

自1985年至1993年我院收治同侧下肢长骨骨折并急性膝关节不稳定病人24例,采用早期手术内固定治疗长骨骨折,短期内二次手术处理膝关节不稳定及次要骨折部位。经6个月至9年的随访,优良率达75％。本文强调对长骨骨折行坚强内固定术后,对膝关节不稳定明确诊断,尽早处理,全面修复。     

The "patellofemoral joint" problem

In the differential diagnosis of femoropatellar joint disease, three conditions must be considered: (1) peripatellar irritation; (2) chondromalacia of the patella; (3) femoropatellar arthrosis. In approximately 90% of the cases, peripatellar irritation and chondromalacia of the patella can be kept under control by active extension and strengthening exercises for the femoral flexor and extensor musculature. In therapy-resistant cases, arthroscopic surgery can provide the opportunity to influence the pathological gliding process positively. The operative procedure is planned on the basis of clinical and radiological examinations and computed tomography investigations. Dysplasia of the patella, including a lax patella, not only requires lateral release, but also medial tightening whereas patellar insufficiency can be treated successfully by lateral release alone. In our new staging procedure, chondromalacia and femoropatellar arthrosis are differentiated. Stage III chondromalacia is simply smoothed out via arthroscopy. In the treatment of femoropatellar arthrosis, on the other hand, restitution of the cartilage defect is of most importance. The age of the patient and staging of the cartilage defect determine which therapeutic procedure is to be used. The "release" operations in the treatment of femoropatellar arthrosis serve to relieve the damaged cartilage area and depend on the axial positioning of the knee joint.     

Isolated arthrosis of the patellofemoral joint in younger patients (<50 years)

In the majority of cases, arthrosis of the patellofemoral joint (PFJ) is combined with arthrosis of the femorotibial compartment and thus assumes a somewhat secondary role. Nevertheless, it can occur as an isolated entity. Several radiological studies evidenced isolated degenerative alterations in the PFJ in the age group >55 years (13.6-24.0% in women and 11.0-15.4% in men). In younger patients the incidence is lower and is mainly associated with patellar instability or post-traumatic arthrosis. Just the same, the choice of appropriate treatment for these patients is challenging. Total replacement can be recommended for older and less active patients. In contrast, for younger and more active patients, various conservative treatment options and more demanding operative techniques are available to the surgeon to avoid arthroplasty. This article describes the different therapeutic possibilities for managing arthrosis of the PFJ in patients aged <50 years.     

Indications and technique of arthrodesis of the knee joint (author's transl)

The indications of an arthrodesis of the knee joint have changed and seem to be rare in a century of total arthroplasty. However, even nowadays the arthrodesis of the knee joint is still carried out with good results in: postinfectious gonarthrosis, irreparable posttraumatic instability, Charcots knee, Neoplastic destructions in special cases, for patients with a severe painful and deforming arthrosis of any reason, which are too young for an arthroplasty and in a century of arthroplasty for all patients after failure of arthroplasty. Within a period of 11 years from 1969-1980, 105 patients underwent an arthrodesis of the knee joint at BG Unfallklinik Tübingen. Indications and technique are given, the value of an individual postoperative care is pointed out.     

Isolierte Arthrose des Patellofemoralgelenks beim jüngeren Patienten (<50 Jahre)

In the majority of cases, arthrosis of the patellofemoral joint (PFJ) is combined with arthrosis of the femorotibial compartment and thus assumes a somewhat secondary role. Nevertheless, it can occur as an isolated entity. Several radiological studies evidenced isolated degenerative alterations in the PFJ in the age group >55 years (13.6–24.0% in women and 11.0–15.4% in men). In younger patients the incidence is lower and is mainly associated with patellar instability or post-traumatic arthrosis. Just the same, the choice of appropriate treatment for these patients is challenging. Total replacement can be recommended for older and less active patients. In contrast, for younger and more active patients, various conservative treatment options and more demanding operative techniques are available to the surgeon to avoid arthroplasty. This article describes the different therapeutic possibilities for managing arthrosis of the PFJ in patients aged <50 years.     

Akute mediale Seitenbandverletzung am Kniegelenk

The medial collateral ligament complex (MCL) is the most commonly damaged ligamentous stabilizer of the human knee. The diagnostic algorithm comprises patient history, clinical examination and magnetic resonance imaging (MRI). It is important to distinguish between incomplete and complete ruptures of the MCL. For adequate treatment the classification and exact knowledge about concomitant injuries are important. A nonoperative treatment of incomplete ruptures (grades I and II) is widely accepted and usually results in a good clinical outcome but the treatment of complete ruptures (grade III) is a subject of controversy. Complete intraligamentous ruptures with a correct approximation of the stumps and intact dorsomedial joint capsule can also be treated nonoperatively with good and excellent results. In contrast, ruptures close to the abutment and bony avulsions tend to heal better through operative treatment. Dehiscence or dislocation of the ligament stumps in MRI is an indication for operative treatment. In the context of a multiligamentous injury or complex instability, the majority of authors suggest an operative stabilization. As the treatment of chronic instability can be challenging, the initial and adequate treatment of acute ruptures is of great importance.     

Analysis of the collective term "periarthritis humeroscapularis"]

The functional and anatomical consideration of the shoulder joint in relation to the clinical aspects can differentiate the general term of "scapulohumeral periarthritis". The most frequently pathological findings are seen in the rotary cuff and the long head of the biceps muscle. Significant causes are further arthrosis of the acromioclavicular joint, the instability of the shoulder joint and the frozen shoulder. The exact diagnosis of the disease makes on operative therapy possible.     

Operative oder konservative Therapie der Außenbandruptur am oberen Sprunggelenk?

To determine whether operative treatment is superior to conservative therapy, 60 patients were randomized to surgical suture and cast immobilisation for six weeks (n=30) or cast immobilisation alone for the same time (n=30) for acute rupture of the ligaments of the ankle. Variables of well being (ability to work, to do sports, disaesthesia, pain during exercise, swelling, tendency for recurrent distorsion), stability (dislocation and tilting of the talus on X-ray examination) and the radiological evidence of arthrosis were chosen as endpoints. Complete follow up was obtained one year after the accident. In both groups we did not find any evidence of arthrosis one year after the accident. No significant differences were found between the study groups neither for the parameters of well being nor for objective criteria of stability. No correlation was found between well being and stability of the ankle joint. These results suggest that for the chosen endpoints no treatment modality can be recommended after one year follow up. Only long-term studies using incidence of arthrosis as the most important endpoint will be able to answer the question whether conservative or operative treatment of rupture of the ankle ligaments is superior.     

Dislocations and fracture dislocations of the metacarpophalangeal joint of the thumb

Due to its exposed position, the MCP joint of the thumb is particularly vulnerable to dislocations and fracture dislocations. Depending on the direction of the injuring force, injuries to the ulnar, radial, and volar aspect of the joint can occur. If high-grade lesions are not identified and treated appropriately during their acute phase, marked instability with associated long-term disability due to weakness and pain in pinch and grip can result. In the absence of a reliable method for diagnosing the Stener lesion, surgical repair of acute, third-degree lesions on the ulnar side of the joint remains the treatment of choice. In the presence of chronic instability, a variety of effective soft tissue reconstructive measures are available. The fact that both acute and chronic injuries enjoy a favorable prognosis with operative repair is due to the fact that operative intervention reliably restores stability to the joint. Mild to moderate loss of motion at the joint is well tolerated functionally. For this reason, arthrodesis remains an exceptionally satisfactory salvage for failed soft tissue reconstructions.     

Ulnakopfprothese nach Trauma

The distal radioulnar joint (DRUJ) is one of the main stabilizing structures in the forearm and, together with the antebrachial interosseous membrane, the relevant forearm muscles and the proximal radioulnar joint (PRUJ), essential for stable forearm rotation. DRUJ injuries are the most frequent cause of both acute and chronic post-traumatic wrist pain, often due to arthrosis. Treatment is difficult and the most frequent method, total ulnar head resection, is often associated with forearm instability, pain and weakness. Implantation of an ulnar head prosthesis, in contrast, restores DRUJ and forearm stability by replacing the ulnar head together with anatomic reconstruction of the triangular fibrocartilaginous complex. This procedure is now being used not only for failed emergency surgery, but also as primary treatment of DRUJ arthrosis. It is possibly also suitable for early reconstruction following irreversible damage to DRUJ joint surfaces.     

Process breaks. A diagnostic problem in ankle injuries

Peripheral talar fractures are frequently overlooked and should be considered in the differential diagnosis of patients with acute and chronic ankle pain. Early diagnosis allows specific treatment options to prevent long-term complications and enables better overall results. Computertomography is obligatory for definite evaluation of the pathology and to determine the need for conservative or operative treatment. Conservatively treated displaced fractures lead to pain and decreased range of motion from ongoing arthrosis of the subtalar joint. Large or displaced fragments require, according to the scare literature, open reduction and internal fixation. Comminution or small fragments are best addressed by surgical excision, although alteration in the biomechanics of the subtalar joint may occur.