Suture of the meniscus in acute instability of the knee joint

The authors describe a multiform function of the menisci and the causes of frequently occurring simultaneous injuries of the meniscus and of the ligament. In 26 cases of acute instability of the knee the authors put sutures over the meniscus. In all the cases the results were good, there were no complications and there was no need to make a repeated operation in any of the cases. Making use of the suture over the meniscus, it is possible to improve the results of the surgical treatment of instability of the knee to a greater extent.     

Arthrosis following knee joint instability and its surgical prevention]

Authors describe the more important injuries that must be corrected by all means during the operative treatment of the acute instability of the knee joint to prevent later arthrosis. They call attention to the fact that in the treatment of the acute instability of the knee joint the prevention of the arthrosis can be realized only with a reconstructive operation, performed in time and with modern technique. The biomechanical causes of the arthrosis, developing during the persistent instability are analysed. The extraarticular operative methods used by them in chronic cases are described.     

关节镜下膝关节急慢性训练伤的诊断分析

目的 探讨军训及运动中膝关节稳定装置急慢性损伤的临床诊断与镜下诊断及其病理改变的差异程度。方法 97例膝关节训练损伤患者通过关节镜观察进行诊断，分析急性及慢性膝关节损伤的诊断及病理改变差异程度。结果 急性损伤(受伤6周之内)33例，临床诊断误诊率：ACL9.1％，PCL3.0％，半月板12.1％，二联征及三联征分别为6.1％及3.0％。慢性损伤64例，临床误诊率：ACLI1.6％，半月板4.7％，二联征及三联征各为1.6％。急性损伤合并软骨退变损伤5例(15.2％)，慢性损伤合并软骨退变性损伤25例(39.1％)，其中慢性膝关节损伤中韧带损伤合并软骨损伤20例，占80.0％。结论 急性膝关节损伤，由于关节肿胀、剧痛，临床检查受限，误诊率较高，应及早行关节镜检查，以提高诊断率。关节软骨损伤与关节损伤后不稳有关。慢性膝关节损伤引起软骨损伤的合并症，明显高于急性期，病程越长，软骨损伤越重。疑有韧带损伤、关节不稳、半月板损伤的患者应及早行韧带及半月板修复，以减少继发性软骨损伤。     

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。     

Surgical treatment of knee joint ligaments]

Because injuries of the ligaments of the knee joint, during 11 years 58 operations have been performed by the authors. In order to evaluate the late results, all patients have been reexamined 1 to 10 years after the operation. In more than the half of the cases at the least 2 ligament injuries have been operated on. 31 patients underwent the operation within two weeks after the injury, and the other patients later on. The authors' material and results are compared also with the data of the literature. In the authors' opinion the result of the surgical treatment is not decisively depending on the chosen operative method. The early and exact diagnosis--forming the basis of the suitable treatment--are of far greater importance. The perfect operative technique and the consequent rehabilitation are indispensable requirements of all surgical interventions. After severe ligament injury of the knee joint the surgical intervention allowed to 2/3 or 3/4 of the injured patients to return to work with stabilized knee. In younger patients also sporting may be possible. Therefore the surgical treatment of the knees, which became unstable because of ligament injury, is absolutely indicated in patients in working age.     

Surgical treatment of an unstable varus knee: one-stage or two-stage?

We present a case of a young female athlete with chronic knee instability and constitutional varus limb, in which the failure of an initial stabilising operation required multiple operations to correct the unstable varus knee: in particular valgus osteotomy and ligament reconstruction using contralateral patellar tendon were performed in two staged operations in order to minimise surgical aggression, optimise rehabilitation and prevent postop complications. The final result is evaluated according to the IKDC chart as normal category A.     

Carbon fiber replacement of the ligaments of the shoulder girdle and the treatment of lateral instability of the ankle joint

A normal active human being will not accept chronic instability or persistent luxation of any joint. Many attempts have been made to stabilize a damaged joint with autogeneic and allogeneic materials and by various surgical techniques. In animal and clinical trials, carbon fibers are reported to be a promising material for ligament replacement in chronic joint instability. The authors are investigating carbon fibers not only for repair of chronic instability of knee joints but also for chronic luxations and subluxations of the sternoclavicular, acromioclavicular, and ankle joints. For long-term stability of the new ligament, carbon fibers must be implanted in cancellous bone channels. Ingrowth of connective tissue and newly formed bone produces a secure ligament anchorage. A temporary tension band wire loop immobilizes the sternoclavicular or acromioclavicular joint. The ankle ligament replacements are immobilized with a weight-bearing plaster boot for six weeks postoperation. The use of carbon fibers as a ligament replacement in the sternoclavicular, acromioclavicular, and ankle joints produces favorable functions and stability. Reconstruction of the normal ligament insertions of a joint is essential, particularly with respect to supination and free range of movement. Of 56 cases with lateral chronic instability of the ankle, 51 with a mean average postoperative follow-up period of two years, 49 had subjectively good results. Stable joints were demonstrable in 48 cases; supination was limited in four cases.     

Experience with 250 dynamic, proximal muscular pedicled, anterior cruciate ligament-plasties (Lindemann)

The diagnostic steps and the indications for the treatment of chronic instability of the knee joint due to rupture (lesion) of the anterior cruciate ligament are discussed. After briefly mentioning the surgical technique we report on 250 dynamic surgical replacements of the anterior cruciate ligament by the proximally based gracile (semitendinous) tendon. For the operations performed between 1976 and 1983 a technique similar to Lindemann's was used. We would like to stress the importance of the reconstruction of injured synergistic stabilizators. The results of a control 1 to 8 years (mean 38 months) after the operation were very good in 21.2%, good in 66.8%, moderate in 9.2%, unsatisfactory in 1.6% and poor in 1.2% of the cases, although strict standards had been applied. We therefore recommend this technique for the treatment of lesions of the anterior cruciate ligament. Thorough after-treatment is of utmost importance for its outcome.     

When is surgery indicated in anterior knee instability? Considerations on operative and functional treatment

Rupture of the ACL may result in chronic anterior knee instability. However, in the majority of patients the secondary stabilizers of the joint such as collateral ligaments, menisci, and the capsule will compensate for this instability. We recommend surgical reconstruction of the acute rupture of the ACL only in the young, active athlete. Concomitant ruptures of capsuloligamentuous structures do not indicate surgical treatment: they may be treated by a plaster cast or a splint with good results. Chronic symptomatic anterior knee instability should first be treated by a vigorous muscle-training program. Surgery is performed only for those patients who cannot compensate for their instability after this rehabilitation program.     

Klinische Ergebnisse der primären Kreuzbandreinsertion nach Palmer ohne Augmentation

The clinical importance of primary cruciate ligament reconstruction without augmentation-plasty is discussed on the background of long term results following 51 operations. Based on standardized methods of evaluation 38 patients had a very good and good result, in eleven cases the operation lead to a fair and in two cases to a poor result. A significant instability with a pivot shift grade III was recorded in two cases; twelve patients showed a low degree of instability whereas 37 patients had regained full stability. The coincidence of a cruciate ligament lesion and a rupture of a collateral ligament had a negative influence on the postoperative long term result (p<0.01). Our results suggest that a primary repair without augmentation-plasty is a qualified procedure for stabilizing the knee joint in cases with an acute femoral rupture without accompanying collateral lesions. In patients with old ruptures or a complex joint lesion primary repair with augmentation is recommended.     

Instability of the proximal tibiofibular joint

Injury to the proximal tibiofibular joint is typically seen in athletes whose sports require violent twisting motions of the flexed knee. Instability of this joint may be in the anterolateral, posteromedial, or superior directions. With acute injury, patients usually complain of pain and a prominence in the lateral aspect of the knee. A closed reduction should be attempted in patients with acute dislocation. If this is unsuccessful, open reduction and stabilization of the joint with repair of the injured capsule and ligaments can be done. Patients with chronic dislocation or subluxation report lateral knee pain and instability with popping and catching, which may be confused with lateral meniscal injury. Symptoms of subluxation may be treated nonsurgically with physical therapies such as activity modification, supportive straps, and knee strengthening. For patients with chronic pain or instability, surgical options include arthrodesis, fibular head resection, and proximal tibiofibular joint capsule reconstruction.     

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.     

Results of surgical treatment of knee instabilities

Between January 1, 1981 and January 5, 1987, 146 reconstructive operations for acute (39) and chronic (107) knee instabilities were performed. THe majority of the acute cases were anteromedial (24), and of the chronic instabilities, 33 were anteromedial, 14 anterolateral, and 53 combined anteromedial-anterolateral. In terms of suture, replacement, and reinforcement of the damaged structures of the acute cases, 32 were good, 6 fair, and 1 poor, while the reconstruction, according to Müller, for chronic instabilities produced good results in 34, fair in 59, and poor in 14. It is essential that such operations be performed by a trained surgical team. For success, precise knowledge of anatomy, exact examination, accurate diagnosis, adequate surgical techniques, and careful postoperative treatment are essential.     

Bilateral, atraumatic, proximal tibiofibular joint instability

Dislocation of the tibiofibular joint is rare and usually results from a traumatic event. Only 1 case of atraumatic proximal tibiofibular joint instability in a 14-year-old girl has been reported in the literature, however this condition might occur more frequently than once thought. A wide range of treatment options exist for tibiofibular dislocations. Currently, the first choice is a conservative approach, and when this fails, surgical means such as resection of the fibula head, arthrodesis, and reconstruction are considered. However, no consensus exists on the most effective treatment. This article reports a unique case of bilateral, atraumatic, proximal tibia and fibular joint instability involving a 30-year-old man with a 20-year history of pain and laxity in the right knee. The patient had no trauma to his knees; he reported 2 immediate family members with similar complaints, which suggests that this case is likely congenital. After conservative approaches proved to be ineffective, the patient underwent capsular reconstruction using free autologous gracilis tendon. At 6-month postoperative follow-up, the patient was pain free with no locking and instability. He then underwent surgery on the left knee. At 1-year follow-up after the second surgery, the patient had no symptoms or restrictions in mobility. We provide an alternative surgical approach to arthrodesis and resection for the treatment of chronic proximal tibiofibular instability. In the treatment of chronic tibiofibular instability, we believe that reconstruction of the tibiofibular joint is a safe and effective choice.     

膝关节周围骨折术后关节不稳的危险因素分析

目的：探讨造成膝关节周围骨折术后关节不稳的危险因素。方法从我科2010年10月至2013年7月住院患者中选取符合纳入标准的膝关节周围骨折病例116例,其中男67例,女49例,平均年龄(47.3±14.4)岁。车祸伤54例,摔伤50例,高处坠落伤6例,机器绞伤3例,殴打伤2例,重物砸伤1例。所有患者均随访12个月。选取年龄、性别、糖尿病史、原发暴力、骨折程度、开放性损伤、韧带损伤、关节囊损伤、术中出血量、手术时间、冠状位胫股角、伸直受限、屈曲受限为初筛因素,先纳入一元Logistic回归模型,再将有关联性的因素纳入多元Logistic回归模型,寻求造成膝关节周围骨折术后关节不稳的危险因素。结果一元Logistic回归分析发现,骨折程度、开放性骨折、韧带损伤、关节囊损伤情况、术中出血量和关节屈曲受限与术后关节不稳有关,差异均有统计学意义(均P<0.05)。多元Logistic回归分析发现,上述关联因素中,关节囊损伤和屈曲受限是造成膝关节周围骨折术后关节不稳的危险因素,差异均有统计学意义(均P<0.05)。结论关节囊损伤和屈曲受限是造成膝关节周围骨折术后关节不稳的主要危险因素。因此,在膝关节周围骨折的外科治疗过程中,积极修复损伤的关节囊,避免术中切开关节囊,术后早期功能锻炼,避免关节屈曲受限,能降低术后关节不稳的发生率,促进关节功能的恢复。     

Das Akromioklavikulargelenk

Acute or chronic instability and osteoarthritis of the acromioclavicular (ac) joint may cause significant impairment of the shoulder. In this continuing education report, the pathomorphology of acute ac dislocations is described based on the Rockwood classification. Decision making on conservative or surgical treatment is discussed. Surgical techniques are presented as acromioclavicular or coracoclavicular procedures. Persistent complaints may warrant additional surgical therapy after conservative treatment as well as after primary surgical treatment. In these cases, residual instability must be addressed. A modified Weaver-Dunn procedure is presented in detail. In any patient with shoulder pain, osteoarthritis of the ac joint has to be taken into consideration. Resection of the lateral clavicle has proved to be effective in these patients.     

The acromioclavicular joint

Acute or chronic instability and osteoarthritis of the acromioclavicular (ac) joint may cause significant impairment of the shoulder. In this continuing education report, the pathomorphology of acute ac dislocations is described based on the Rockwood classification. Decision making on conservative or surgical treatment is discussed. Surgical techniques are presented as acromioclavicular or coracoclavicular procedures. Persistent complaints may warrant additional surgical therapy after conservative treatment as well as after primary surgical treatment. In these cases, residual instability must be addressed. A modified Weaver-Dunn procedure is presented in detail. In any patient with shoulder pain, osteoarthritis of the ac joint has to be taken into consideration. Resection of the lateral clavicle has proved to be effective in these patients.     

A treatment concept using external transfixation in unstable defect trauma of the knee joint

The main problems in the treatment of severe knee injuries with extensive soft tissue damage, ligamentary lesions and compound fractures consist in the high risk of infection and complex instability of the joint. 20 patients suffering such type of trauma were treated by a schedule comprising an extensive debridement and a combination of minimal internal osteosynthesis and external transfixation. Secondary operations were always performed as a second look in all patients and various surgical reconstructions of the soft tissue coverage under continuous protection of the external fixation. Most patients obtained satisfactory functional results, only 2 cases ended up with arthrodesis due to deep infection.     

膝关节内侧副韧带损伤修复方法改进

目的　探讨膝关节内侧副韧带损伤修复的新方法 ,以早期获得满意的功能效果。方法　对 11例早期膝关节内侧副韧带损伤患者行椎管麻醉下探查膝关节内侧副韧带损伤的病理改变 ,一期缝合修补断裂韧带 ,并切取 1/ 2宽的半腱肌腱 ,加强修复损伤韧带。 1例陈旧性损伤用股薄肌重建膝内侧副韧带。结果　平均随访 2 5个月 ,优 9例 ,良 2例 ,关节稳定有力 ,B彲ｈｌｅｒ征阴性 ,膝关节活动功能正常 ,恢复原工作。结论 :膝关节内侧副韧带损伤多在止点 ,早期修复为好 ,同时切取邻近腱性结构加强修复 ,更加稳定可靠 ,功能效果恢复较好     

肘关节不稳的诊断治疗

肘关节不稳是急性骨折脱位及慢性运动劳损中常见的肘部疾患,对于急性肘关节不稳的治疗至关重要,及时治疗避免形成慢性不稳.慢性不稳治疗较为困难.本文综述了肘关节不稳的表现、诊断及治疗.肘关节不稳的治疗原则为将复杂的骨折脱位变为简单的骨折脱位,恢复解剖结构,包括关节面和软组织.肱尺关节损伤时外侧组织的修复尤为重要.肘关节复发性不稳应以手术治疗为主.