Ligament reconstruction and tendon interposition for advanced posttraumatic arthritis of the proximal interphalangeal joint: 3 case reports

Although prosthetic replacement of the proximal interphalangeal (PIP) joint can restore function, it is associated with high rates of complications and is considered unsuitable for active young patients. Resection arthroplasty of the PIP joint offers an alternative, but it requires adequate soft tissue integrity and cannot correct lateral instability. The authors present an alternative resection arthroplasty technique for the PIP joint, which includes collateral ligament reconstruction and tendon interposition using a free tendon graft. This procedure can be performed in advanced posttraumatic arthritis of the PIP joint and provides acceptable motion and adequate lateral stability.     

手部近指间关节闭合性损伤的基础与临床研究

目的 探讨近指间关节(proximal interphalangeal joint,PIP)闭合性损伤的解剖特点及不同结构损伤的治疗及预后.方法 通过对20个成年人新鲜尸体手指标本的解剖学研究,了解近指间关节损伤及关节囊挛缩发生的机制.临床上对21例近指间关节损伤的患者进行手术.结果 解剖学研究发现,副韧带及掌板近侧损伤对近指间关节活动度无明显影响.侧副韧带损伤主要破坏关节侧方的稳定性,掌板损伤主要破坏关节前后方的稳定性.21例术后随访3～13个月,平均7个月.各指近指间关节主动屈、伸活动范围:屈曲60°～95°,平均78°;背伸0°～15°,平均8°.被动屈、伸活动范围:屈曲71°～98°,平均82°;背伸0°～18°,平均11°.结论 对于掌板及侧副韧带损伤,应尽早进行手术修复及止点重建,可防止关节囊挛缩.     

Thumb collateral ligament injuries. An anatomic basis for treatment

This anatomic and clinical study leads to the following conclusions: 1. The ulnar and radial proper collateral ligaments are the critical lateral stabilizers of the thumb MP joint; both are highly vulnerable to complete disruption, with resultant disabling joint instability. 2. The intrinsic anatomy of the radial side of the MP joint is not a mirror image of the ulnar aspect. Significant anatomic differences account for distinctive patterns of instability. Whereas disruption of the ulnar collateral ligament in conjunction with dorsal capsular tears is apt to result in combined radiovolar subluxation, disruption of the radial collateral ligament, coupled with the unopposed dynamic force of the adductor pollicis, characteristically is prone to a rapid pathologic sequence of profound joint instability, with progressive ulnar and volar subluxation and, ultimately, degenerative joint disease. 3. Optimal management of the complete collateral ligament lesion requires prompt diagnosis, most accurately confirmed with physical and radiographic stress testing, and precise surgical repair. Immobilization alone is insufficient treatment for these serious ligament disruptions, characterized by considerable displacement with wide separation of torn ends. 4. Although early direct repair affords the best opportunity for restoration of joint integrity with a highly favorable functional recovery, secondary repair and free tendon grafting, prior to joint deformity, provide consistently successful options for chronic instability.     

自体半腱肌腱重建距腓前韧带和跟腓韧带治疗踝关节外侧不稳

目的探讨自体半腱肌腱重建距腓前韧带和跟腓韧带治疗踝关节外侧不稳的临床效果及安全性。方法对16例踝关节外侧不稳患者行自体半腱肌腱重建距腓前韧带和跟腓韧带手术,观察踝关节功能情况。结果患者均获得随访,时间1~3年。术后6、12个月摄踝关节内翻应力位X线片未见距骨倾斜,均未发生复发踝关节外侧不稳。术后AOFAS评分为83.52分±7.26分,明显高于术前的50.45分±4.58分。踝关节功能评定:优8例,良7例,可1例。结论自体半腱肌腱重建距腓前韧带和跟腓韧带治疗踝关节外侧不稳疗效确切,安全性高,是一种较为理想的术式。     

Treatment of medial ligament injuries of the knee

The anatomic structures of the knee form a complex transmission system that coordinates joint position and provides stability for knee function. Ligament injury produces abnormal kinematic states that interfere with normal knee function. Because of the unequal load-sharing between the ligaments and musculotendinous units that occurs with ligament injury, complex instability patterns can develop, compromising the functional capability of the knee. Joint damage can also develop. The surgeon must restore stability to the knee by providing the appropriate tension in the anatomic structures, thus stabilizing the tibiofemoral joint and reestablishing a more normal load-sharing function of the capsular envelope and intra-articular ligaments. Isolated, limited instability, grade III medial ligament injuries can be treated nonoperatively with bracing that allows limited motion and with a high-repetition exercise program. The examiner must be aware that complex problems also can occur with grade III injuries, adversely affecting nonoperative outcome and leading to chronic instability. For more severe acute medial ligament injuries, the surgeon can accomplish acute surgical restoration of the anatomy including the mid-third capsular ligament, tibial collateral ligament, posterior oblique ligament, semimembranosus complex, and other injured knee structures (ie, anterior cruciate ligament, meniscus, vastus medialis obliquus, and semimembranosus). A well-supervised rehabilitation program follows treatment. Reconstruction of chronic medial ligament tears produces poor results.     

Aktuelle operative Therapiestrategien bei chronischer Akromioklavikularsgelenkinstabilität

Chronic instability of the acromioclavicular joint (AC joint) results if the initial acromioclavicular joint luxation has been missed or if the rehabilitative or surgical treatment was not successful. Late repairs after a traumatic luxation are difficult to deal with because the biological healing response for reconstitution of the ligaments seems to be compromised. A meticulous diagnostic examination should be performed paying special attention to the character and direction of instability (static versus dynamic and vertical versus horizontal). For this purpose a specified classification system should be used (Hedtmann and Heers). A new surgical technique for stabilization of chronic AC joint instability has been established and biomechanically evaluated. The technique includes an augmented modified coracoacromial ligament (only the medial half of the ligament) transfer supplemented by coracoclavicular polyester augmentation. In an in vitro model the technique was shown to restore anterior and superior translation of the intact AC joint. An increase of translation compared to the level of the intact joint was statistically significant only for the posterior direction (127%, 3.8 mm intact versus 4.6 mm following reconstruction; p<0.05). Therefore, for further improvement of the technique some form of acromioclavicular ligament reconstruction (posterosuperior) could be profitable. In conclusion the presented surgical technique (augmented CA ligament transfer) reveals promising biomechanical results in an in vitro model and may serve as an alternative to current coracoclavicular ligament reconstruction techniques using autologous tendon grafts.     

Clinical and functional outcome after anatomic and nonanatomic ankle ligament reconstruction: Evans tenodesis versus periosteal flap.

The present study investigated the effects of two different surgical procedures for the treatment of chronic ankle instability. Ten patients treated with an anatomic reconstruction using a periosteal flap were compared with a second group that received an Evans tenodesis. All patients were evaluated before and after surgery with clinical and radiographic examinations as well as dynamic pedobarography. Patient satisfaction and radiographic and functional results were comparable in both groups and revealed a good restoration of joint stability and gait symmetry. Our results indicate that both methods of ankle ligament reconstruction achieve a comparable clinical and functional outcome within 1 year after surgery.     

The “All Inside” Arthroscopic Broström Procedure: A Prospective Study of 40 Consecutive Patients

Lateral ankle sprains are the most common injury in sports. Nonoperative therapy is recommended initially, including functional rehabilitation. Surgery might be an option for those patients in whom nonoperative attempts fail. Various surgical approaches have been described in published studies for treating chronic lateral ankle instability. The procedures are typically grouped into 2 main categories: anatomic and nonanatomic repair of the lateral ligament complex. The open modified Broström-Gould anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization. In the present study, we used an arthroscopic approach to treat chronic anterior talofibular ligament tears without the extensive open incisions common in the traditional modified Broström-Gould procedure. Our hypothesis was that the use of an all-inside arthroscopic Broström procedure would provide a minimally invasive technique with acceptable patient outcomes. We also wished to explore the complication rates and interval to return to weightbearing activity. A total of 40 ankles in 40 consecutive patients were included in the cohort.     

Laterale Instabilität des oberen Sprunggelenks

Because of their frequency, ankle sprains are of major clinical and economic importance. The simple sprain with uneventful healing has to be distinguished from the potentially complicated sprain which is at risk of transition to chronic ankle instability. Conservative treatment is indicated for the acute, simple ankle sprain without accompanying injuries and also in cases of chronic instability. If conservative treatment fails, good results can be achieved by anatomic ligament reconstruction of the lateral ankle ligaments. Arthroscopic techniques offer the advantage of joint inspection and addressing intra-articular pathologies in combination with ligament repair. Accompanying pathologies must be adequately addressed during ligament repair to avoid persistent ankle discomfort. If syndesmotic insufficiency and tibiofibular instability are suspected, the objective should be early diagnosis with MRI and surgical repair.     

Open reduction and internal fixation for dorsal fracture dislocations of the proximal interphalangeal joint using a miniplate

Various operative techniques have been described for unstable dorsal fracture dislocations of the proximal interphalangeal (PIP) joint with articular involvement. However, this injury still remains a therapeutic challenge for hand surgeons because no single technique guarantees successful outcomes. We performed a novel procedure using a low-profile miniplate, which allows for anatomic reduction, rigid internal fixation, and early finger joint motion. Between March 2003 and May 2009, 18 consecutive patients who suffered from 19 dorsal fracture dislocations of the PIP joint with volar articular fracture of the middle phalanx involving more than 40% of the articular surface were treated using this technique. The postoperative follow-up period averaged 16.6 months (range, 12-18 mo). Bony union was obtained in all cases. No patient showed residual dorsal subluxation. Active motion of the PIP joint averaged 85.0 degrees (range, 62-105 degrees), flexion contracture averaged 5.4 degrees (range, 0-17 degrees), and percent total active interphalangeal joint motion averaged 89.0% (range, 60%-100%). Two patients had restricted active distal interphalangeal joint flexion owing to tendon adhesion resulting from the use of a relatively long plate in the first few cases of this series. No major complications were reported for the other 16 patients. We describe the surgical technique, indications, complications, and postoperative management for this technique.     

The rotator interval: anatomy, pathology, and strategies for treatment

Over the past two decades, it has become accepted that the rotator interval is a distinct anatomic entity that plays an important role in affecting the proper function of the glenohumeral joint. The rotator interval is an anatomic region in the anterosuperior aspect of the glenohumeral joint that represents a complex interaction of the fibers of the coracohumeral ligament, the superior glenohumeral ligament, the glenohumeral joint capsule, and the supraspinatus and subscapularis tendons. As basic science and clinical studies continue to elucidate the precise role of the rotator interval, understanding of and therapeutic interventions for rotator interval pathology also continue to evolve. Lesions of the rotator interval may result in glenohumeral joint contractures, shoulder instability, or in lesions to the long head of the biceps tendon. Long-term clinical trials may clarify the results of current surgical interventions and further enhance understanding of the rotator interval.     

Surgical Treatment of Subtalar Joint Instability: Safety and Accuracy of a New Technique in a Cadaver Model

New surgical strategies to treat symptomatic subtalar joint (STJ) instability are evolving. We modified a previously described reconstruction strategy and then refined our new surgical technique through simulated surgery and subsequent cadaver dissections. Our purpose was to show that a tunnel intended to facilitate STJ stabilization surgery could safely be drilled across the footprints of the interosseous talocalcaneal ligament (ITCL). A percutaneous fluoroscopically guided tunnel for the purpose of ITCL reconstruction was created in 10 cadaveric below-knee specimens. Accuracy of the tunnel with relation to the anatomic boundaries of the ITCL attachment sites as well as damage to relevant structures at risk were recorded. Two sets of 5 surgeries were performed to assess for improvement in technique. Mean distances from the tunnel to the ITCL on the calcaneus improved between groups 1 and 2: 4.04 and 1.80 mm, respectively (p = .04). Mean distances from the tunnel to the ITCL on the talus improved between groups 1 and 2: 6.2 and 1.8 mm, respectively (p = .08). With information obtained from this study, an osseous tunnel can be safely placed within 2 mm of the ITCL footprints.     

单一外侧入路治疗肘部损伤"三联征"的修复技巧及疗效分析

目的 探讨采用单一肘关节外侧入路治疗肘部损伤"三联征"的手术扩大显露、修复技巧及临床疗效.方法 对2007年5月至2010年3月收治的6例肘部损伤"三联征"患者采用单一肘关节外侧入路,由深至浅依次修复下列结构:冠状突骨折、桡骨头骨折、外侧副韧带、伸肌总腱起点.并用自创的方法对冠状突骨折进行扩大显露,直视下复位与牢靠固定,对肘关节外侧结构的撕裂进行有效修复.本组患者均未做肘关节内侧副韧带的探查与修复.随访时采用Mayo肘关节功能评分(MEPS)对患者肘关节功能进行评价.结果 本组患者随访3～24个月,平均11个月.所有患者骨折均获骨性愈合,肘部屈伸活动度105°～135°,平均120.0°;前臂旋转活动度150°～170°,平均168.3°;MEPS评分93～95分,平均93.3分,均为优.所有患者均无伤口感染,伤口一期愈合.结论 单一肘关节外侧入路结合相应手术技巧的改进,解决了肘部损伤"三联征"中冠状突骨折复位与固定的疑难问题,对肘关节外侧结构的修复也更加简单、牢靠,是一种临床可行且疗效满意的手术方式.     

Arthroscopically Assisted Reduction and Percutaneous Fixation of Dorsal Perilunate Dislocations and Fracture-Dislocations

Perilunate injuries are severe disruptions of the wrist joint that produce variable patterns of injury to the carpal anatomy. Most surgeons advocate an open reduction followed by ligament repair or internal fixation. We tried to reduce and fix the carpal bones under arthroscopic control to minimize surgical trauma and to preserve blood supply. While viewing the articular surface with the arthroscope, the disrupted proximal carpal row was anatomically reduced using Kirschner wires as joysticks, and fixed percutaneously without any repair of the capsuloligamentous tears. Three patients with dorsal perilunate dislocations or fracture-dislocations were treated by this technique. All the patients achieved accurate reduction and stable fixation, and showed successful healing of the carpal fractures with proper alignment after 10 to 12 weeks of immobilization. At 16 to 22 months follow-up, all patients showed normal radiographic findings with no evidence of instability or arthritis. The arthroscopic treatment of acute dorsal perilunate injuries is technically feasible in achieving anatomic reduction and stable fixation. Our preliminary clinical results were encouraging, but the long-term results need to be observed.     

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.     

Augmented lateral ankle reconstruction using a free gracilis graft.

This article describes a surgical technique for reconstruction of the unstable ankle that uses a modification of the Elmslie procedure for anatomic augmentation of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). Our technique is an anatomic reconstruction that uses a free graft of the gracilis tendon toreconstruct the CFL and A TFL.     

Anatomic Posterolateral Corner Knee Reconstruction

Injuries to the lateral collateral ligament and posterolateral corner of the knee, particularly when combined with anterior cruciate or posterior cruciate ligament injuries, can result in profound symptomatic knee instability. Although many surgical improvements have been made in reconstruction of anterior and posterior cruciate ligament injuries, reconstruction of the posterolateral corner has had less predictable results, with residual pathologic laxity especially in the chronic situation. This has stimulated many surgeons to recommend acute repair of posterolateral knee injuries. This article describes a more anatomic reconstruction of the posterolateral corner for chronic instability, recreating the lateral collateral ligament and popliteofibular ligament using either autogenous or allograft soft tissue and an interference screw technique. In a small clinical series, this has proven to restore varus rotation and external rotation patholaxities with a high degree of predictability.     

Rekonstruktion des vorderen Kreuzbandes

Rupture of the anterior cruciate ligament (ACL) is a common acute injury representing a pre-arthrotic deformity whether treated surgically or not. Surgical treatment in actively sportive patients with instability should be prompt. The most frequently used transplantations include hamstring tendons and the middle third patellar tendon. Both transplantats achieve good results, although the hamstring tendons produce less donor site morbidity. The standard surgical technique is the 1-bundle reconstruction with anatomic positioning of the bone tunnel. The femoral tunnel should be placed over the anteromedial portal, to enable a lateral position. Fixation should be close to the joint without damaging the transplant. Hybrid fixation with the hamstring transplant seems to achieve the best primary stability.     

Comparison of isometric and anatomic reconstruction of the medial patellofemoral ligament: a cadaveric study

Recent surgical procedures designed to correct recurrent posttraumatic lateral patellar instability focus on reconstructing the medial patellofemoral ligament. This study evaluated and compared patellofemoral kinematics of isometric and anatomic medial patellofemoral ligament reconstructions. Using an infrared motion capture analysis system, patellar tracking was evaluated in the coronal plane in 6 cadaveric specimens. Reconstruction of the medial patellofemoral ligament using an isometric technique did not restore normal patellar tracking at any flexion angle; however, reconstruction using an anatomic technique restored statistically normal patellar tracking from maximal knee extension to 28 degrees of flexion. Neither technique was able to restore normal kinematics in deeper angles of knee flexion.     

Posttraumatic widening of the lateral aspect of the radiohumeral joint space on unstressed anteroposterior elbow radiograph: a predictive sign of elbow instability

We present a case of incomplete or perched irreducible elbow dislocation, which occurred spontaneously into cast immobilisation performed for a diagnosis of “elbow sprain”. Initial anteroposterior unstressed elbow radiograph revealed a subtle widening of the lateral aspect of the radiohumeral joint space. Because of the unusual irreducibility of this subluxation, the patient underwent surgical exploration which showed the lateral collateral ligament complex and capsule to be interposed into the radiohumeral joint space and interfering with elbow reduction. This case report intends to draw attention on the radiographic sign of widening of the radiohumeral joint space on the unstressed anteroposterior elbow radiograph as a predictive sign of instability and to document the anatomic lesion that leads to this presentation.