Grade I and II acromioclavicular dislocations: results of conservative treatment

The purpose of this study was to assess the results of acute grade I and II acromioclavicular (AC) joint sprains treated by conservative measures. Between 1993 and 1997, 37 consecutive patients were treated conservatively for AC joint sprains, grade I and II in the Tossy classification. Of these patients, 4 were excluded (three lost to follow-up and one sustained a further AC injury), leaving a series of 33 patients. Among them, in 9 (27%), chronic AC joint pathology that required subsequent surgery developed at a mean of 26 months after injury. The remaining 24 were reviewed clinically and radiologically at a mean of 6.3 years (range, 4-8 years) after injury. At the latest follow-up, 17 of the 33 patients (52%) remained asymptomatic. Of the 24 patients reviewed, 7 complained of activity-related pain. Eight patients presented with residual anteroposterior instability. Tenderness at the AC joint as well as a positive cross-body test was observed in 12 patients. The mean Constant score at follow-up was 82 points. The x-ray films showed degenerative changes in 13 patients, ossification of the coracoclavicular ligaments in 2, an association of degenerative changes with ossification of the coracoclavicular ligaments in 3, and distal clavicular osteolysis in 3. Only 4 cases had no radiographic changes after this kind of AC injury. On the basis of these results, we conclude that the severity of the consequences after grade I and II AC sprains is underestimated.     

Long-term results of conservatively treated medial collateral ligament injuries of the knee joint

The purpose of the study was to determine the long-term healing potential of nonoperatively treated isolated sprains of the medial collateral ligament (MCL) of the knee joint. A multidimensional follow-up analysis was performed an average of nine years after injury, with 54 patients with Grade II sprains (partial tear of the MCL) and 27 patients with Grade III (complete tear) sprains. The methods used included four standardized knee scoring scales for subjective, objective, functional, and roentgenographic evaluations, as well as isokinetic and isometric strength evaluations. The outcome in Grade II sprains of the MCL was generally good, even though some residual medial laxity was common. In Grade III sprains the outcome was much worse, with a high frequency of persisting medial instability, dysfunction of the anterior cruciate ligament, muscle weakness, and posttraumatic osteoarthritis of the injured knee. Grade II sprains of the MCL respond acceptably to nonoperative treatment, whereas in Grade III sprains such treatment is not the method of choice.     

带绊纽扣钢板治疗TossyⅢ型肩锁关节脱位的临床研究

目的：初步探讨采用带绊纽扣钢板内固定治疗肩锁关节脱位的临床疗效。方法：2007年7月至2008年12月采用带绊纽扣钢板内固定治疗TossyⅢ型肩锁关节脱位27例,男17例,女10例;年龄23-60岁,平均（35．0±1．3）岁;交通事故伤14例,工伤6例,运动伤4例,摔伤3例;左侧16例,右侧11例。均为TossyⅢ型,无合并锁骨骨折。治疗后参照Karlsson评价标准,根据肩部活动度、疼痛程度、肌力及肩锁关节复位X线表现情况进行疗效评定。结果：27例均荻随访,时间6～14个月,平均10．2个月,根据疗效标准,优24例,良2例,差1例。结论：带绊纽扣钢板内固定可靠,手术创伤小,更符合生物力学,可早期功能锻炼,为治疗肩锁关节脱位提供了新的选择。     

Die Balser-Platte mit Bandnaht Eine zuverlässige Stabilisierungsmethode des Akromioklavikulargelenks

Between June 1990 and December 1997 116 patients with complete dislocation of the acromio-clavicular joint were treated operatively. According to the classification of Tossy and Rockwood all patients had type Tossy III or Rockwood III, IV and V of lesion. The retrospective part of the study from June 1990 to August 1994 represents 48 patients treated in 31 cases with wire-cerclage, in 14 cases with PDS-cerclage and in 3 cases with a combination of Kirschner wires and PDS. In a second group between September 1994 and 1997 68 patients were treated operatively with a special hook-plate, called Balser-plate, combined with suture of the corakoclavicular ligaments, the articular capsule and the intraarticular discuss. In the first group there was a postoperative immobilisation of the injured shoulder for 2,3 weeks necessary; in comparison to non immobilisation at the Balser-plate group. The range of motion in the Balser-plate group was free up to 90 degrees abduction. The removal of implants was performed in both groups after approximately 3 month. Postoperative complications were 8 reluxations at the acromio-clavicular joint and 10 superficial infects at the Non-Balser group and 4 superficial infects and 2 subcutaneous haematoma in the Balser group. We saw no reluxation in the Balser group. We examined 30 of 48 patients of the Non Balser group after average 50.1 month and 57 of 68 patients of the Balser group after 24.6 month. We compared the functional result, a questionnaire and the ultrasound examination of the acromio-clavicular joint with and without 10 kg weight bearing of the arm. 87.7% of the Balser patients and 67.7% of the Non-Balser-patients had free movement of the injured shoulder. Another 14.2% and 11.4% of the Balser group complained on shoulder pain with weight bearing and extreme moval in comparison to 17.4% of the Non-Balser group. At ultrasound examination comparing the injured to the non injured arm with and without 10 kg weight bearing there was a clavicula-elevation of 0.3 mm and 0.6 mm at Balser-patients and 3.0 mm and 2.5 mm at Non-Balser-patients for the injured side. In normal position the acromio-clavicular width was physiological in 50.2% of Balser patients in comparison to 36.6% of Non-Balser-patients. Under weight bearing the acromio-clavicular width increases in both groups. 63.2% of the Balser-group patients are satisfied with the result of operation, but only 43.3% of the other group (p < 0.05). Completely dissatisfied were 20% of the Non-Balser group, particularly because of the bad cosmetic result (40%).     

Acute lateral ankle sprains in track and field athletes: an expanded classification

We present a longitudinal observational study on classification of acute lateral ankle ligament injuries in track and field athletes, based on objective criteria. These very common and sometimes troublesome sports injuries are treated functionally, but there is a lack in international literature on predicting the time needed for full recovery. Taking into consideration (1) active range of motion, (2) edema, (3) stress radiographs findings, and (4) full rehabilitation time, we divided grade III sprains in IIIA and IIIB, proposing that these injuries can be classified in four categories (I, II, IIA, IIIB). The range of motion-edema-stress radiographs classification that we propose evaluates the severity of lateral ankle injuries, is an easy and practical method, and predicts full return in athletic activities without residual complaints, if the proper rehabilitation program is executed.     

Stabilization of the injured shoulder joint with PDS cord]

A successful treatment of the acromioclavicular separation is the repair of the acromioclavicular and coracoclavicular (CC-)ligaments and a stable reduction of the acromioclavicular (AC-)joint. To avoid dangerous breakage and migration of the K-wire an abduction humeral splint is necessary immobilizing the injured shoulder for 5-6 weeks. In the years 1987-1989 40 patients suffering AC-separation were treated (34 Tossy III separations, 4 Tossy II separations, 2 Tossy I separations). In these cases a stable reduction was achieved by a transarticular K-wire fixation and a combination of AC- and CC-fixation by loops. In 1987 wire loop was used. In 1988 a combination of wire and Polydioxanon (PDS) loops was used. The PDS-loop, a slowly resorbable suture material, fixed the CC-ligament. In 1989 the AC-joint was stabilized by a PDS-loop as well. The examination of 31 patients 6-24 months after the operation showed good clinical results no matter whether PDS-loops or wire loops were used. The advantage of the transarticular K-wire fixation in combination with PDS-loops was the easy removal, which could be done in mostly of the cases as an outpatient procedure. An operation of the AC-Tossy III separation on patients beyond their 4. decade should be well considered. A long time of treatment, remaining pain and a limitation of shoulder movement must be expected.     

Arthroscopic partial medial meniscectomy in patients over 40 years old: A 5- to 11-year follow-up study

A retrospective analysi sof 68 knees from 65 patients older than 40 years, who had undergone a partial medial meniscectomy, was carried out. The average age of the patients was 49.7 years (range, 40 to 74), and themean follow-up period was 7.8 years (range, 5 to 11). The patients were divided into two groups based on the degree of articular cartilage degeneration. Group I consisted of 53 knees that did not have any significant articular cartilage damage beyond grade I or II. Group II consisted of 15 knees that had grade III or IV cartilage damage. Overall, excellent results were obtained in 44 patients (47 knees), good results in 10 patients, fair results in six patients, and poor results in five patients. In group I, 46 knees (87%) had an excellent outcome, and only one patient had a poor result. In contrast, patients in group II had significantly worse results, with only one knee (7%) having excellent outcome, and four knees had a poor result. A specific history of trauma did not affect the clinical outcome. Forty-two patiens (64%) were able to resume normal athletic activities without any restrictions. Arthroscopic partial medial meniscectomy in patients older than 40 years is an acceptable and effective long-term treatment, particularly in patients without significant articular cartilage damage.     

AC-Verletzungen: konservativ-funktionelle Therapie und Ergebnisse

Injuries involving the acromoclavicular joint account for more than 10% of all injuries to the shoulder girdle, making them the second most frequent type of shoulder injury. When categorized as Tossy I or II such injuries are generally treated conservatively, whereas Rockwood IV–VI injuries are treated operatively. There is still no agreement on the best way of treating Tossy class III injuries. More than 35 conservative treatments have been proposed, and over 50 operative methods. Regardless of the method of treatment applied, relatively good functional results are obtained. Persisting prominence of the clavicle cannot reliably be reduced by strapping, but the reduced shoulder strength that has been claimed to follow conservative treatment has not been verified by strength testing. Furthermore, after surgery rehabilitation takes longer, the period of inability to work and to engage in sporting activities is extended, and the complication rate is higher, in addition to which the costs of surgical treatment are higher. "Skillful neglect" of Tossy I–III injuries combined with brief immobilization of the shoulder joint, cryotherapy and functional treatment seems to be the method of choice even in patients whose work involves hard physical labour and in active athletes.     

Pathogenetic aspects of complex treatment of Dupuytren's contracture in patients with chronic hepatitis

The results of Dupuytren's contracture treatment in patients, suffering chronic hepatitis with the hand deformity grade II and III, in the injured persons and liquidators of the Chernobyl disaster consequences, conducted in 2000-2010 yrs., were adduced. Beginning from the third week, when an active movements had emerged, the patients were treated locally, including lidase and solution, which consisted of dimexid, isotonic saline and furazolidon.     

Non-Hodgkin's lymphomas of the stomach. Therapy from the surgical viewpoint]

About 2-5% of all gastric tumours are Non-Hodgkin Lymphomas (NHL). In the last years we treated 15 patients with NHL of the stomach. Six of these patients were classified to group IE according to Ann Arbor classification, four to group II (three II 1 E and one II 2 E). In group III E were two patients (one III S and one III E) and one patient was classified to group IV. Ten patients displayed low grade and five high grade malignancies with respect to the Kiel classification. We performed in group I three gastrectomies and three BI resections. In four patients of group II two gastrectomies and two BI resections were carried out and in group III two BI resection. Our treatment policy consisted of operation and radiation in IE, to operation and chemotherapy in high grade lymphomas of group II, and operation plus radiation in low grade malignancies of group II. In group III we treated radiation, chemotherapy and operation and in group IV radiation and chemotherapy. In group I five patients survived, in group II two out of four and in group III one of two. The patient of group IV died within two years after diagnosis.     

Surgical treatment of acromioclavicular joint injury

The acromioclavicular joint plate according to Rahmanzadeh allows the safe retention of the reset acromioclavicular joint in stage Tossy III and in exceptional cases also in stage Tossy II traumata when simultaneous early functional post-treatment is done from the first postoperative day on. The clinical results obtained after follow-up examinations of 53 of the 83 patients treated in this way were mostly good or very good. Perfect radiological results were obtained in 50% of these patients; 40% showed a slight subluxation and 10% a marked but pain-free subluxation.     

Behandlung der AC-Luxation mit einem Bohrdraht und PDS-Kordel

Dislocations of the acromioclavicular joint are common injuries in sports and traffic accidents. The most widely used classification of these injuries is the one of Tossy, Tossy III and Tossy II injuries are indications for operative treatment. Among several different surgical approaches a very common procedure is the temporary fixation of the AC-joint by two pins, tendon band wiring and suturing of the ligaments. Recently we have been using a temporary transfixation by only one pin, tension band fixation with PDS and suturing of the ligaments. The advantages of this method are: preservation of clavicular rotation, easier operation and metal removal, and less damage of the joint cavity. Results and complications are presented.     

Stand der Therapie der Schultereckgelenkverletzung Ergebnisse einer Umfrage an Unfallchirurgischen Kliniken in Deutschland

The therapy of acromioclavicular dislocations remains controversial. In particular, for injuries classified as Rockwood/Tossy Type III good results have been reported with different operative techniques as well as with conservative treatment. The objective of this study was to obtain data about the current treatment for Rockwood/Tossy III injuries in German trauma departments. In a countrywide anonymous survey 210 German trauma departments were asked about their diagnostic procedures and their treatment strategies for acromioclavicular injuries. 104 questionaires (49%) were returned and evaluated. In Rockwood/Tossy I/II injuries most clinics recommend conservative treatment (Rockwood/Tossy I/II: 99% / 87%). On the other hand, 84% of the clinics would operate on Type III acromioclavicular injuries – especially in athletes or overhead workers. Although 38 percent of the clinics believe that conservative treatment is equal or better than operative treatment, only 13 percent manage Type III injuries conservatively. For more severe acromioclavicular injuries (Rockwood IV to VI) all clinics recommend an operative treatment. The operative techniques of choice for acromioclavicular injuries are K-wire fixation (37%) or a coraco-clavicular cerclage (32%). Of the latter, 73% use a resorbable material, while the remainder use wires.     

带线铆钉治疗TossyⅡ、Ⅲ型肩锁关节脱位

 目的 探讨带线铆钉治疗TossyⅡ、Ⅲ型肩锁关节脱位的疗效。
方法 2008年1月至2009年2月,治疗TossyⅡ、Ⅲ型肩锁关节脱位患者31例,男19例,女12例;年龄33～49,平均41岁;TossyⅡ型9例,Ⅲ型22例。其中新鲜肩锁关节脱位19例,陈旧性肩锁关节脱位9例,锁骨钩接骨板固定失败3例;患者均不合并骨折。手术均采用Mitek 3.0mm带线铆钉植入喙突,以不可吸收尾线穿过锁骨固定脱位,同时修复喙锁韧带或转移喙肩韧带;其中12例采用克氏针辅助固定。采用日本骨科协会（Japanese Orthopaedic Association,JOA）肩关节疾患治疗判定标准和肩锁关节脱位评分系统对术后疗效进行评价。
结果 31例患者均获得随访,随访时间11～23个月,平均17个月。单纯铆钉固定组术后JOA肩关节疾患评分为65~95分,其中优8例、良9例、可1例、差1例,优良率为89.47%（17/19）;铆钉结合克氏针固定组术后JOA肩关节疾患评分为74~97分,其中优5例、良4例、可3例,优良率为75.00%（9/12）。两组肩锁关节脱位评价系统的优良率分别为94.74%（18/19）和91.67%（11/12）。5例患者在拔除克氏针1~ 3个月后出现肩锁关节复位部分丢失,但肩关节活动范围较术后无明显变化,未进一步治疗。
结论 带线铆钉治疗T ossyⅡ、Ⅲ型肩锁关节脱位,具有手术创伤小,并发症少,避免二次手术的特点,术后疗效肯定。     

Zuggurtung und Bandnaht bei Zerreißung des Akromioklavikulargelenks

Summary Goal of Surgery Reduction of dislocations of the AC joint and its maintenance by internal fixation. Indications Acute and chronic AC dislocations of Tossy type III in patients with high occupational and athletic demands. Lateral clavicular fractures and pseudarthroses. Contraindications Acute and chronic AC separations of Tossy type I and II. Local infections. Lack of patient's cooperation. Positioning and Anaesthesia Supine, beach chair position. General anaesthesia. Surgical Technique Open reduction of the AC joint, internal fixation with tension band wiring and suture of the torn ligament through a sabre cut incision. Postoperative Management Velpeau dressing until complete wound healing. Active mobilization to the level of the horizontal plane after wound healing. Implant removal after 6 to 8 weeks followed by complete range of motion exercises. Possible Complications Wire breakage. Inadequate reduction. Migration of wires. Redislocation. Posttraumatic osteoarthritis. Injury of subclavian artery or brachial plexus. Results 46 out of 57 patients had a normal postoperative course, in 4 an infection occurred. A loosening of the internal fixation was observed 6 times, 4 out of 57 patients could be followed-up at an average of 21.5 months. 40 patients had an excellent or good result, and 7 had a satisfactory or poor outcome. In 37 patients a normal range of motion was found.

     

Retrospective review of outcome post open reduction and K-wire fixation for grade III acromioclavicular joint subluxations

There is controversy about the therapy for grade III acromioclavicular dislocation according to Tossy and Rockwood’s classification. We identified 25 patients who underwent acromioclavicular joint wiring for grade III subluxations under the care of a single consultant in the last 5-year period. All patients were asked to fill in a DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire to assess outcome following acromioclavicular joint repair, and their clinical notes were reviewed. Our results show that open reduction and Kirschner- (K) wire fixation of grade III AC joint disruptions results in good strength and range of motion of the affected shoulder. It is associated with DASH scores, which are comparable to those of the general population for the same age, indicating little residual disability. All patients returned to their pre-injury occupation, and all but one returned to previous sporting activities. Complications occurred in four patients, but only one required K-wire repositioning.     

Surgical repair of acute collateral ligament injuries in digits with the Mitek bone suture anchor

Eighteen acute grade III collateral ligament injuries were treated by using the Mitek bone suture anchor. Seven were thumb metacarpophalangeal joint injuries, and eleven were finger proximal interphalangeal joint injuries. Seventeen patients were followed more than 12 months after surgery. All patients were able to use the digits in daily living activities within 5 weeks after surgery, and return to their original work or sports activities within 12 weeks. Pain was completely relieved in 15 patients. Loss of joint motion averaged 7 degrees. In all joints the postoperative lateral stress angle was within 10 degrees of that of the contralateral digit.     

缝合锚重建喙锁韧带治疗Tossy Ⅲ度肩锁关节脱位

目的 评估使用缝合锚治疗Tossy Ⅲ度肩锁关节脱位的临床疗效.方法 2005年3月至2006年12月,使用缝合锚治疗25例TossyⅢ度肩锁关节脱位患者,男18例,女7例;年龄17-53岁,平均29.3岁.所有患者均使用缝合锚重建断裂的喙锁韧带,恢复喙突及锁骨的解剖对位关系.术后采用Constant评分评价肩关节功能,术后1年x线片评价治疗结果.结果 25例患者均获得随访,随访时间6～24个月,平均13.5个月.术后3周肩关节可恢复活动,3～4个月后上肢可进行非负重体育活动,4～6个月上肢活动基本恢复正常.按Constant疗效评定标准:肩关节功能评分为94.5分,主观评分为1.3分.术后1年x线片示肩锁关节无再脱位及缝合锚断裂现象.结论 缝合锚治疗肩锁关节脱位,创伤小,复位同定、确实,术后功能恢复好.     

Capsular injuries of the proximal interphalangeal joint.

Although capsular injuries of the PIP joints are common, their management is frequently complicated. Successful treatment must begin with a detailed history because reviewing the mechanism of injury may provide information relevant to the pathomechanics of the capsular disruption and facilitate making an accurate diagnosis. Grades I and II volar plate and collateral ligament sprains represent the vast majority of PIP joint injuries. They are best treated with a short period of dorsal splinting followed by supervised mobilization. Although splinting is also applicable for grade II sprains associated with instability and most grade III sprains, the initial period of immobilization should be longer. The prognosis for recovery is generally good, although some residual tenderness or joint stiffness are common complications. Dorsal capsular injuries, if unrecognized, result in deformity rather than instability. The majority of these injuries can also be treated by closed means, but they require more prolonged immobilization and more commonly result in reduced mobility than volar plate and collateral ligament injuries. Capsular injuries that are compound, irreducible, or associated with a large intraarticular fracture can result in serious problems. Frequently, these injuries require primary surgical treatment, particularly in the case of the irreducible dislocation, which always requires surgery. An exception to the generally poor prognosis of these injuries is the irreducible volar dislocation because the central tendon remains intact permitting early postoperative joint mobilization. A chronic dislocation or late instability are fortunately not common sequela of capsular injuries; however, when they do occur, surgery is required.     

Athletic activity after total joint arthroplasty

Demand for total joint arthroplasty is projected to increase in the first three decades of the twenty-first century. With increasing frequency, patients who have a hip or knee replacement expect to, and choose to, participate in athletics following rehabilitation. In general, patients who have had a hip or knee replacement decrease their participation in, and intensity of, athletic activity following the total joint arthroplasty. The orthopaedic literature on athletic activity after total joint arthroplasty is limited to small retrospective studies with short-term follow-up. Expert opinion regarding appropriate athletic activity after total joint arthroplasty is available from the Hip Society and the Knee Society. When patients who have undergone joint replacements choose to participate in athletic activity, orthopaedic surgeons should provide information with which to evaluate the risk of sports activity and recommend appropriate athletic activity.