Surgical versus nonsurgical treatment of ligamentous injuries following dislocations of the elbow joint

Sixty-two patients older than 16 years of age at the time of injury were reexamined an average of five years (range, 1 to 12 years) after a dislocation of the elbow without concomitant fracture. Thirty-four were treated nonsurgically with closed reduction and immobilization in a plaster cast. Twenty-eight were treated surgically with primary ligament repair followed by immobilization in plaster. Ligament repair was performed medially in all cases and laterally in 17, on the average two days after injury. At follow-up examination, the most common complaint in both groups was limited range of motion, decreased extension being the most common. In no respect were the surgically treated elbows better than those treated nonsurgically. No evidence was found to recommend primary surgical treatment of ligament injuries associated with dislocation of the elbow.     

Surgical versus non-surgical treatment in patients with esophageal varices--a prospective randomized study]

In Japan, non-shunting procedures and selective shunt such as esophageal transection (ET), and distal splenorenal shunt (DSRS) have been widely performed. A prospective randomized trial was done to assess the effects of EIS and DSRS for treating patients with esophageal varices. Ninety-six Japanese with good liver function (Child A or B) and large esophageal varices were randomly assigned to one of three groups given different treatments; (EIS, n = 32), (ET, n = 32) and (DSRS, n = 32). Five patients (15.6%) of the DSRS group has to be excluded from this study, because of severe chronic pancreatitis. No patient died within 30 days of the treatments. The 5-year cumulative bleeding rates were 0%, 4.3% and 12.1% in the EIS, ET and DSRS groups, respectively, with no statistical significances. In no case in the three groups did the death occur because of variceal bleeding. Nineteen patients died mainly due to the underlying liver disease; 5 in the EIS, 5 in the ET and 9 in the DSRS group. There was no statistically significant difference in the survival rates among the three groups. We conclude that EIS is a satisfactory alternative to ET or DSRS for the management of patients with large esophageal varices.     

Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study

BACKGROUND: Open reduction and internal fixation is currently the accepted treatment for displaced Lisfranc joint injuries. However, even with anatomic reduction and stable internal fixation, treatment of these injuries does not have uniformly excellent outcomes. The objective of this study was to compare primary arthrodesis with open reduction and internal fixation for the treatment of primarily ligamentous Lisfranc joint injuries. METHODS: Forty-one patients with an isolated acute or subacute primarily ligamentous Lisfranc joint injury were enrolled in a prospective, randomized clinical trial comparing primary arthrodesis with traditional open reduction and internal fixation. The patients were followed for an average of 42.5 months. Evaluation was performed with clinical examination, radiography, the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, a visual analog pain scale, and a clinical questionnaire. RESULTS: Twenty patients were treated with open reduction and screw fixation, and twenty-one patients were treated with primary arthrodesis of the medial two or three rays. Anatomic initial reduction was obtained in eighteen of the twenty patients in the open-reduction group and twenty of the twenty-one in the arthrodesis group. At two years postoperatively, the mean AOFAS Midfoot score was 68.6 points in the open-reduction group and 88 points in the arthrodesis group (p < 0.005). Five patients in the open-reduction group had persistent pain with the development of deformity or osteoarthrosis, and they were eventually treated with arthrodesis. The patients who had been treated with a primary arthrodesis estimated that their postoperative level of activities was 92% of their preinjury level, whereas the open-reduction group estimated that their postoperative level was only 65% of their preoperative level (p < 0.005). CONCLUSIONS: A primary stable arthrodesis of the medial two or three rays appears to have a better short and medium-term outcome than open reduction and internal fixation of ligamentous Lisfranc joint injuries.     

Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study

Two hundred consecutively seen patients who had an injury to either the anterior cruciate ligament or the medial collateral ligament, or both, were randomly allocated to treatment by either conservative or a surgical regimen. Injuries to the medial collateral ligament could not be demonstrated to benefit from surgical treatment in any respect--with or without surgery the results were excellent. With injuries to the anterior cruciate ligament, recovery was more rapid without surgery but otherwise the results differed between the groups in only one respect: the pivot-shift test was more often positive after conservative treatment. The results were good in both treatment groups even though most of the patients who had an injury of the anterior cruciate ligament were somewhat less pleased with the outcome after a period of time.     

手术治疗右肘腕关节复杂损伤病例1则——骨科经典病例大赛个案道

正患者女性,42岁,因"摔伤致右肘、腕部肿痛活动受限3 h余"于2015年6月27日13:10入院。患自述3 h前在山上摘杨梅时从杨梅树上摔下致伤,当即感右肘部及右腕部肿胀、疼痛,活动受限,疼痛呈持续性,活动时加剧。但患者受伤后一直无昏迷、无恶心呕吐,无胸闷气促,无腹痛腹胀,无大小便失禁。急诊于一个体诊所摄片(图1~2)示:右肱骨髁间粉碎性骨折,骨折端移位;右舟状骨骨折,月骨周围背侧脱位,予"右     

The unstable elbow joint following dislocation. Diagnosis and therapy

The meaning of instability after elbow dislocation (unstable dislocation) is pointed out. We support the trend to surgical treatment in cases of obvious instability and emphasize a differentiated concept in diagnosis and therapy. 32 patients after elbow dislocation were treated and followed up after an average period of 7.5 months. Good to very good results could be achieved in 24/32 patients (75%).     

严重肘关节损伤治疗方案的选择与思考

<正>严重肘关节损伤的治疗至今仍存在困难且预后欠佳,使肘关节外科成为国内外研究的一个热点。近些年来,国内外骨科医生对肘关节损伤的研究逐渐深入,对肘关节生理功能及肘关节损伤的认识也越来越全面,新的治疗方法、治疗手段不断涌现,进一步提高了肘关节损伤的疗效。尤其在国内,近些年骨科医生对肘关节损伤的认识和治疗有了突飞猛进的进步。我国人口基数大,肘关节损伤     

Surgical treatment of acute type V acromioclavicular injuries. A prospective study.

In a prospective study, 28 consecutive patients with an acute Type V acromioclavicular sprain were treated with a coraco-clavicular repair using a double velour Dacron graft. All patients were reviewed after a mean follow-up period of 5.1 years (range: 1 to 9 years). At follow-up, 20 patients (71.4%) showed good or excellent results, according to the Imatani evaluation system, and 8 patients (28.6%) demonstrated a fair or poor result according to the same system. Loss of reduction was encountered in 11 shoulders (40%), despite an initial anatomical reduction. No correlation was seen between the overall scores at follow-up and the degree of residual dislocation, between the overall scores and the presence of coraco-clavicular calcifications or ossifications, between the overall scores and the development of posttraumatic arthritic changes, or between the overall scores and the presence of osteolysis of the distal clavicle.     

Dislocation of the elbow: an experimental study of the ligamentous injuries

The stability of human cadaveric elbow specimens was investigated using an experimental apparatus. Posterior dislocation of the elbow could only be produced when a combined valgus and external rotatory torque was applied to the specimen. None of the elbows were dislocated during varus and internal rotatory torque or in the extreme positions. In ten elbow specimens with an experimentally produced posterior dislocation, simultaneous rupture of the anterior part of the medial collateral ligament and the annular ligament were the most frequent findings. A lateral collateral ligament tear was only seen in two cases. Posterior elbow dislocation seems to be due to a combined valgus and external rotatory stress to the semiflexed elbow, resulting in a bilateral ligamentous injury.     

The treatment of pulled elbow: a prospective randomized study

To evaluate the effectiveness in decreasing recurrence of cast application after manual reduction of pulled elbow. Sixty-four children with pulled elbow were randomized into two treatment groups: Group A underwent manipulative reduction followed by splinting the elbow in a flexed and supinated position for 2 days; group B underwent manipulative reduction only. Both groups were examined 2, 5, and 10 days later. None of the 33 patients in group A had a pulled elbow at follow-up. Four (13%) of 31 patients in group B had a pulled elbow 2–5 days later. Immobilizing the elbow for 2 days after manipulative reduction improves the success of treatment of a pulled elbow. Received: 25 January 1999     

手法治疗陈旧性肘关节脱位

陈旧性肘关节脱位常因失治误治所致,临床较常见,自2003年3月至2006年5月采用手法复位、中药浸洗治疗陈旧性肘关节脱位57例,效果满意,总结如下。     

Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow

PURPOSE: To review the results of surgical reconstruction of posttraumatic elbow instability in the setting of either intact or repaired olecranon process using a protocol incorporating hinged elbow fixation. METHODS: Thirteen consecutive patients with ulnohumeral instability after a fracture-dislocation of the elbow, adequate articular surfaces, and adequate, stable alignment of the olecranon were treated with temporary hinged external fixation, preservation, or reconstruction of both the coronoid process and radiocapitellar contact and with repair or reconstruction of the lateral collateral ligament complex. There were 9 men and 4 women with an average age of 45 years. Seven patients had a terrible triad pattern injury and 6 had a posterior Monteggia pattern injury. All 13 patients had fracture of the radial head and 10 patients had fracture of the coronoid process. RESULTS: At an average follow-up period of 57 months stability was restored in every patient. The average Disabilities of the Arm, Shoulder, and Hand questionnaire score was 15 and the average Mayo score was 84, with 6 excellent, 4 good, and 3 fair results. The average arc of ulnohumeral motion was 99 degrees. Six patients had radiographic signs of arthrosis including 5 of 6 patients with olecranon fracture-dislocations. CONCLUSIONS: A stable, functional elbow can be restored in most patients with persistent instability after fracture-dislocation of the elbow using a treatment protocol incorporating hinged external fixation.     

Surgical treatment of chronic dislocation of the sterno-clavicular joint.

The costo-clavicular ligament is always ruptured in dislocation at the sterno-clavicular joint. Anterior, superior or posterior displacement of the medial end of the clavicle may occur. Acute dislocation usually responds to conservative treatment and operation is seldom required. Chronic, or recurrent, dislocation may cause pain and disability on strenuous activity and necessitate surgical treatment. The operation of tenodesis of the subclavius tendon with capsulorrhaphy described by Burrows (1951) has been adopted. The intraarticular meniscus is often damaged and displaced, and may block reduction; its removal is then necessary. In addition, a threaded Stinmann pin transfixing the joint has been found useful to maintain the stability of reduction. The operation has been performed on five patients, four of whom had excellent results. The fifth patient disrupted the repair in a drinking bout shortly after the operation.     

Conservative or surgical treatment of acromioclavicular dislocation. A prospective, controlled, randomized study

In a prospective, controlled, randomized study of acute acromioclavicular dislocations, we compared conservative and operative treatment (the Phemister procedure) with regard to the clinical results, complications, and social costs. Forty-one patients were operated on and forty-three patients were treated conservatively. Two patients who were operated on and three who were treated conservatively had to have the lateral extremity of the clavicle resected because of pain. The rehabilitation period was significantly shorter with non-operative treatment, and after thirteen months there was no difference in the clinical results. There were no serious postoperative complications, but about half of the patients who were operated on had problems with the metallic device, such as breakage or migration of the pins, or both, and six patients had a superficial infection. For most patients with total acromioclavicular dislocation we recommend conservative treatment with a sling until the patient is free of pain. Operation should be considered in thin patients who have a prominent lateral end of the clavicle, in those who do heavy work, and in patients whose daily work requires that the shoulder often be held in about 90 degrees of abduction and flexion.     

Surgical or non-surgical treatment of acute rupture of the anterior cruciate ligament. A randomized study with long-term follow-up

One hundred and eleven consecutive patients who had acute injuries to the knee that included rupture of the anterior cruciate ligament, as shown by physical examination with the patient under anesthesia and by diagnostic arthroscopy, were randomized to three treatment groups: simple repair of all injured structures, repair of all injured structures and augmentation of the anterior cruciate ligament with a strip of the iliotibial band, and repair of all injured structures except the anterior cruciate ligament. In all other respects, the knees were treated in an identical fashion. Of the 111 patients, 107 were re-examined forty-five months or more after operation. At the most recent follow-up, the knees that had been treated by repair and augmentation of the anterior cruciate ligament were significantly more stable and had had significantly fewer subsequent meniscal tears. Sufficient instability to necessitate late reconstruction was also less frequent in the patients who had had an augmented repair. These patients had better function of the knee and a higher level of activity than the patients in the other two groups. Sixty-four per cent of these patients who had a rupture of the anterior cruciate also had a meniscal tear, and primary care was indicated for more than 50 per cent of the tears. Therefore, we believe that early arthroscopic examination is essential for patients who have an acute rupture of the anterior cruciate ligament.     

A hinged external fixator for treatment of complex elbow joint injuries

BACKGROUND: The treatment of complex injuries of the elbow joint by a hinged fixator is a new concept of external transfixation with guided movement in a defined monocentric axis. Biomechanical investigations using cadaver specimens showed that the monocentric guidance ensures additional stability in these unstable osteoligamentous injuries, allows early functional treatment, and can be used in primary but also in revision surgery. PATIENTS AND METHODS: Between 1997 and 2004, 23 patients with complex fractures of the elbow joint were treated with a hinged monocentric external fixator after open reduction and internal fixation. The early functional treatment started 6.4 days (mean) postoperatively; the average range of motion (ROM) was 58 degrees. RESULTS: The early functional treatment using a hinged fixator resulted in a mean increase in the range of motion of up to 71 degrees within an average time course of 34.7 days. In 18 patients a significant increase in the ROM was seen; in 4 patients no improvement in the ROM could be achieved. Only one patient showed a decrease in ROM (5 degrees). Follow-up examinations after 10 months revealed a mean ROM of 88 degrees. CONCLUSION: In agreement with the literature, our results provide evidence that the use of a hinged monocentric external fixator in combination with early functional therapy results in an increase in the ROM and represents a beneficial device and concept in the treatment of complex injuries of the elbow joint.