Arthroskopische Wiederherstellung einer Ausrissfraktur des hinteren Kreuzbands am Tibiaansatz

Avulsion fracture of the tibial insertion of the posterior cruciate ligament (PCL) is a rare condition. Until recently, bony avulsion fractures of the PCL have been repaired with open reduction and internal fixation. Posterior approach commonly used for open repair is rather extensive, yet it does not allow for detection and managment of associated intraarticular injuries of the knee. We report a case of avulsion fracture of the tibial attachment of the PCL managed by arthroscopic reduction and fixation. A large bony fragment that extended into the posterior part of the lateral tibial plateau allowed for reduction and retrograde fixation through anterior portals only.     

Management of trans-scaphoid perilunate dislocations

A retrospective review of 28 patients with 29 trans-scaphoid perilunate dislocations who underwent open reduction and Herbert screw fixation is presented. The majority of the patients had satisfactory results at 24 months of follow-up. A significantly better range of wrist motion was obtained in postoperative patients treated with cast immobilization for 4 weeks compared with those treated for longer than 5 weeks. The scaphoid fractures united well, with proper alignment of the carpal bones, regardless of the length of cast immobilization. We recommend open reduction, internal scaphoid fixation using a Herbert screw, carpal ligament repair and early cast removal in the management of trans-scaphoid perilunate dislocations.     

Displaced avulsion fractures of the posterior cruciate ligament: Treated by stellate steel plate fixation

Background:

The open reduction with internal fixation is an effective approach for treatment of avulsion fracture of posterior cruciate ligament. The previously used internal fixation materials including hollow screws, absorbable screw, tension bands and sutures have great defects such as insufficient fixation strength, susceptibility to re-fracture, etc. Stellate steel plate is novel material for internal fixation which has unique gear-like structure design. We used stellate steel plate for treatment of displaced avulsion fractures of posterior cruciate ligament in this study.

Materials and Methods:

14 patients (9 men, 5 women; aged, 19–35 years; mean age, 28 years) with displaced avulsion fractures of the tibial insertion of the posterior cruciate ligament were retrospectively analyzed between June 2009 and June 2011. The mean duration from injury to the operation was 8.3 days (range 6–15 days). All the patients were treated with open reduction and internal fixation of a stellate steel plate (DePuy, Raynham, MA 02767, USA). The Lysholm-Tegner knee function score criteria were used to analyze results.

Results:

The mean followup was 24.6 months (range 18–32 months). After 6 months, all the fractures healed and knee joint activity was normal, with no knee stiffness or instability. The Lysholm-Tegner scores were 97.1 ± 1.7 points at the final followup.

Conclusion:

Owing to its unique gear structure, the stellate steel plate design can effectively fix an avulsion fracture block and it is a simple operation with short postoperative rehabilitation time and firm fixation.     

Arthroscopic reduction and fixation of bony avulsion of the posterior cruciate ligament of the tibia

Bony avulsion fractures of the posterior cruciate ligament of the tibia have commonly been treated by open reduction and internal fixation using the posterior approach. However, this approach, using the prone position, makes it difficult to investigate and treat other combined injuries of the knee joint. We report a case of posterior cruciate ligament avulsion of the tibia that was arthroscopically reduced and firmly fixed with two cannulated screws. The posterior sag was absent after the operation and the result was excellent. By arthroscopy, we got rigid fixation of the avulsed fragment for early rehabilitation, and detection of a concomitant injury was also possible.     

锚钉内固定治疗后交叉韧带胫骨止点撕脱性骨折

目的探讨锚钉内固定治疗后交叉韧带（PCL）胫骨止点撕脱性骨折的临床疗效。方法对32例膝关节PCL胫骨止点撕脱骨折患者,采用膝关节后内侧倒“L”,形入路切开复位,以锚钉内固定治疗,术后给予石膏托固定膝关节屈曲30。约4周,拆除石膏外固定后适当行膝关节伸屈功能锻炼。结果30例获得随访,时间7～30个月,平均（13±5．2）个月。术后2～4个月均获骨性愈合,平均为（3±0．6）个月。手术6个月后依据Lysholm等膝关节评分系统评估膝关节功能,评定优26例,良3例,可1例,优良率96．7％。结论膝后内侧“L”形入路应用锚钉内固定治疗PCL胫骨止点撕脱骨折是安全有效、内固定可靠的,可在早期有效地重建膝关节的稳定性,恢复膝关节功能。     

Fixation of small tibial avulsion fracture of the posterior cruciate ligament using the double bundles pull-through suture method.

BACKGROUND: Avulsion of the tibial insertion of the posterior cruciate ligament is commonly repaired via open reduction and internal fixation with a screw, Kirschner's wire, and suture. In the case of a major bony fragment, this technique is adequate to achieve rigid fixation. In the case of an avulsion fracture with a small bony fragment, however, it is not uncommon to break the bone fragment during screw fixation. We describe a new technique for fixation of an avulsion fracture with a small bony fragment. The technique uses a double bundles pull-through suture technique that repairs the anterolateral and posteromedial components of the posterior cruciate ligament simultaneously. METHODS: From March 1994 through May 1997, 12 patients with small tibial avulsion fractures of the posterior cruciate ligament were treated using this technique. RESULTS: At an average of 18 months after surgery (range, 12-24 months), the preliminary clinical and radiographic results were satisfactory. Eleven patients could return to the same or a higher level of preinjury sports activity. According to the International Knee Documentation Committee rating system, 10 of the 12 patients had normal or nearly normal ratings. CONCLUSION: The double bundles pull-through suture technique can avoid the risk of breakage of the small bony fragment, does not require the removal of hardware, and can achieve adequate repair in the anatomic situation. Our clinical experience suggests that it is a good choice for fixation in cases of avulsion fracture with a small bony fragment.     

Open bicondylar Hoffa fracture associated with extensor mechanism injury

Two cases of open bicondylar Hoffa fracture of the knee associated with extensor mechanism injury are described in two active young patients with multiple fractures. The level of the fracture was determined by the proximal insertion of the posterior cruciate ligament and anterior cruciate ligament in the medial and lateral condyle. The level of the extensor mechanism injury was determined by the degree of flexion of the knee at the moment of impact. No ligament or meniscal tears were found. Open reduction and internal fixation with four lag screws and bone-to-tendon repair of the patellar and quadriceps tendon gave excellent results after more than 2 years of follow-up. The mechanism of injury and the therapeutic implications are discussed, and the literature is reviewed.     

Open Gustilo 1 and 2 midshaft fractures of the radius and ulna in children: is there a role for cast immobilization after wound debridement?

INTRODUCTION: Open fractures of the forearm in children are one of the indications for open reduction and internal fixation. Fixation allows for soft tissue management and maintenance of reduction. This study compares the outcome of open Gustilo 1 and 2 midshaft forearm fractures treated with cast immobilization versus the outcome of those treated with internal fixation after wound debridement. METHODS: This is a retrospective study of the cases of 31 children treated in Kandang Kerbau Women's and Children's Hospital from 1998 to 2005. All had wound debridement, followed by cast immobilization in 15 patients and implant stabilization in 16 others, using plates and screws or intramedullary K-wires. The patients were assessed at final follow-up using the classification by Price. RESULTS: Both treatment groups had 100% excellent or good results. There was no significant difference in time to union. However, there was a higher incidence rate of delayed union and infection when treated with implant stabilization. The main complication associated with cast immobilization was loss of reduction (4 cases), of which 1 case required a second manipulation. DISCUSSION: Despite the trend toward implant stabilization of all open forearm fractures, this study shows that there is still a role for cast immobilization in its treatment of Gustilo 1 and 2 open forearm fractures as long as proper casting technique and close follow-up is achieved. However, internal fixation should be considered in cases where the fracture is noted intraoperatively to be unstable or if attempted reduction fails, bearing in mind the possible complications associated with internal fixation.     

Knee dislocation with ipsilateral femoral shaft fracture: a report of five cases

We report the management and outcome of 4 patients with 5 knee dislocations associated with ipsilateral femoral shaft fractures. All patients were managed by immediate reduction of the knee dislocation, intramedullary nailing of the femur, and angiography, followed by postoperative immobilization of the knee (brace or external fixation) for a minimum of 6 weeks. Four of the 5 dislocations underwent a secondary ligament reconstruction. At the 2-year follow up, the mean Knee Society Score was 133 (range 99-170).     

Acute tibial tubercle avulsion fractures

Acute tibial tubercle avulsion fractures are uncommon, and these injuries typically occur in mature-appearing adolescent boys involved in jumping sports, particularly basketball. The developmental anatomy of the tibial tuberosity and the changes surrounding normal physiologic epiphysiodesis render this structure susceptible to acute avulsion fractures. Possible associated injuries include patellar and quadriceps avulsions, collateral and cruciate ligament tears, and meniscal damage. The treatment of this injury is based on the amount of displacement and associated injuries. Nondisplaced fractures are treated nonoperatively with cast immobilization. Displaced fractures require open reduction and internal fixation. Even in Type III injuries, the outcome is usually excellent.     

Use of a cast compared with a functional ankle brace after operative treatment of an ankle fracture. A prospective,randomized study

BACKGROUND: Controversy continues with regard to the optimal postoperative care after open reduction and internal fixation of an ankle fracture. The hypothesis of this study was that postoperative treatment of an ankle fracture with a brace that allows active and passive range-of-motion exercises would improve the functional recovery of patients compared with that after conventional treatment with a cast. Thus, the purpose of this prospective, randomized study was to compare the long-term subjective, objective, and functional outcome after conventional treatment with a cast and that after use of functional bracing in the first six weeks following internal fixation of an ankle fracture. METHODS: One hundred patients with an unstable and/or displaced Weber type-A or B ankle fracture were treated operatively and then were randomly allocated to two groups: immobilization in a below-the-knee cast (fifty patients) or early mobilization in a functional ankle brace (fifty patients) for the first six postoperative weeks. The follow-up examinations, which consisted of subjective and objective (clinical, radiographic, and functional) evaluations, were performed at two, six, twelve, and fifty-two weeks and at two years postoperatively. RESULTS: There were no perioperative complications in either study group, but eight patients who were managed with a cast and thirty-three patients who were managed with a brace had postoperative complications, which were mainly related to wound-healing. Two patients in the group treated with a cast had deep-vein thrombosis. All fractures healed well in both groups. The difference between the two groups with respect to the complication rate was significant (p = 0.0005). No significant differences between the study groups were observed in the final subjective or objective (clinical) evaluation. At the two-year follow-up examination, the average score (and standard deviation) according to the ankle-rating scale of Kaikkonen et al. was 85 +/- 9 points for the group treated with a cast and 83 +/- 10 points for the group treated with a brace, and the average ankle score according to the system of Olerud and Molander was 87 +/- 8 points and 87 +/- 9 points, respectively. CONCLUSIONS: The long-term functional outcome after postoperative treatment of an ankle fracture with a cast and that after use of a functional brace are similar. Although early mobilization with use of a functional ankle brace may have some theoretical beneficial effects, the risk of postoperative wound complications associated with this treatment approach is considerably increased compared with that after conventional cast treatment. Thus, the postoperative protocol of treatment with a functional brace requires refinement before it can be generally advocated for use after operative treatment of an ankle fracture.     

Screw fixation for certain fractures of the phalanges and metacarpals.

Twenty-one patients with fractures of the bones of the hand were treated by open reduction and internal fixation with compression screws. The firm fixation allowed range-of-motion exercises in most patients to be begun on the third postoperative day. On follow-up mild restriction in digital motion was seen in only one patient, and significant disturbance in joint function was not encountered. In spite of these advantages, the method is indicated in only a small percentage of such fractures. Usually traditional methods of open reduction and internal fixation are preferred when an open procedure is needed. However, oblique and spiral fractures of the proximal phalanx, some fractures with large single articular fragments particularly involving the proximal interphalangeal joint, and appropriate Bennett's fractures are suitable for screw fixation.     

Anterior cervical plate fixation with the titanium hollow screw plate system. A preliminary report

Morscher, of Switzerland, has developed an anterior cervical spine plate system (THSP) that does not require screw purchase of the posterior cortex. This design eliminates potential neurologic complications usually associated with the anterior plate system, but maintains the mechanical advantages of internal fixation. The authors reviewed 13 consecutive patients in whom the THSP system was applied. Indications for the use of this device included acute trauma in three patients, trauma of more than 6 weeks' duration in five patients, and spondylosis in five patients. Fifteen plates and 58 screws were placed, with no screws purchasing the posterior cortex. Postoperative immobilization varied from no immobilization to four-poster brace. With a mean follow-up of 13 months, all 13 patients went on to fusion. One patient had screws placed in the disc rather than in bone and went on to malunion. In all other patients, radiographs did not demonstrate screw migration, screw-bone lucency, graft dislodgement, or malunion. No patient suffered neurologic injury as a result of this device. The THSP system facilitates reliable fusion with minimal complications. Its use should be considered in multilevel anterior spine defects, posttraumatic cervical kyphosis, and cervical fractures with posterior disruption requiring anterior fusion.     

钢丝内固定治疗后交叉韧带胫骨止点撕脱骨折

目的:应用钢丝通过钻孔牵拉内固定治疗后交叉韧带胫骨止点撕脱骨折,评价疗效。方法:2003年1月至2009年6月,28例膝关节后交叉韧带胫骨止点撕脱骨折患者,男19例,女9例;年龄16～55岁,平均35.3岁。X线检查示骨折移位:Ⅱ度10例,Ⅲ度18例。采用膝关节后内侧倒"L"形入路切开复位,以钢丝内固定治疗,术后可调节支具固定,术后2周在CPM辅助下膝关节被动伸屈训练,4周在支具保护下下地部分负重,术后6周拆除支具。结果:25例患者获随访,时间6～24个月,平均15个月。X线片示骨折复位满意,所有患者获得骨性愈合,膝关节稳定,Lachman试验阴性,未发生骨折不愈合和关节僵硬等并发症。伸膝活动度正常,屈膝活动度(136±12)°。采用Lysholm膝关节评分法评估,术前(41.80±6.16)分,术后6个月(94.10±8.26)分,术前术后比较,差异有统计学意义(t=26.667,P<0.01)。术后评定优22例,良2例,可1例。结论:应用膝后内侧倒"L"形入路以钢丝内固定治疗后交叉韧带胫骨止点撕脱骨折具有安全有效、内固定可靠、费用少等优点,可有效重建膝关节的稳定,恢复膝关节功能,是治疗后交叉韧带胫骨止点撕脱骨折较理想的选择。     

Knee instability after fractures of the intercondylar eminence of the tibia

Fifteen children with fracture of the intercondylar eminence of the tibia were reviewed. Three with type I or type II fractures had closed treatment. Twelve with type III fractures had open reduction and internal fixation. Follow-up examination included history and examination of the knee; nine had follow-up radiographs. The mean follow-up period was 7 years. Seven patients were free of symptoms; eight had varying degrees of pain, of which four had to avoid some athletic activities; and two described subluxation episodes. All had normal motion, four had atrophy, and all had some evidence of anterior cruciate ligament laxity. The anterior cruciate ligament probably stretches before its tibial attachment fractures. Even though the fracture heals in its normal position, mild degrees of anterior cruciate ligament laxity often will result.     

Surgical treatment of displaced fractures of posterior column and posterior wall of the acetabulum

We evaluated the results of open reduction and internal fixation of displaced posterior wall and posterior column fractures of the acetabulum. This was a prospective clinical evaluation of such cases where the main surgical strategy was open reduction and internal fixation with interfragmentary screws and reconstruction plates. Data on 11 patients treated by open reduction (all via Kocher-Langenbech approach)/internal fixation with interfragmentary screws and reconstruction plates were collected. The follow-up period was 61 (18-102) months. Reduction with a fracture gap of less than 2mm without articular stepping was achieved in all 11 cases. Postoperative complications developed in five patients, including subcutaneous haematoma in one, avascular necrosis of the femoral head (AVNFH) in one and heterotopic ossification (HO) in three. All but the patient with AVNFH, had anatomic radiological reduction, and good to excellent functional results. Open reduction and internal fixation with interfragmentary screws and reconstruction plates is the treatment of choice in displaced posterior wall and posterior column fractures of the acetabulum.     

Arthroscopic repair of the posterior cruciate ligament: Two techniques

Summary: Isolated posterior cruciate ligament injuries are rare and their treatment is controversial. These lesions have commonly been treated by open reduction and internal fixation using a posterior approach. However, this approach makes it difficult to explore other combined injuries of the knee joint. We report 2 cases of posterior cruciate ligament avulsion of the tibia that were arthroscopically reduced and fixed using 2 different methods, cannulated screws and tension band wire.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 6 (September), 2000: pp 656–660     

Posterior bicondylar tibial plateau fractures

OBJECTIVE: To present a case series of patients with posterior bicondylar tibial plateau fractures treated by direct fracture exposure and fixation through dual incisions. DESIGN: Retrospective clinical study. SETTING: Level 1 trauma centers. PATIENTS/PARTICIPANTS: Eight patients were identified that had posterior bicondylar tibial plateau fractures. Two patients had depressed posterolateral tibial plateau fractures with contained defects and did not have direct fracture exposure. One patient died of medical problems leaving 5 patients who underwent direct fracture exposure, reduction, and fixation. INTERVENTION: Posteromedial followed by posterolateral open reduction and internal fixation of posterior bicondylar tibial plateau fractures. RESULTS: At 6 to 24 months follow-up (mean 13 months), all patients returned to near full activities, each with aching after prolonged standing (8-hour shift). Range of motion averaged 2 degrees to 121 degrees of flexion. Three of 5 returned to manual labor jobs; the others were not employed at the time of injury. CONCLUSIONS: Posterior bicondylar tibial plateau fractures have a high association with lateral meniscal pathology and can be associated with anterior cruciate ligament injury. Reduction of the posterior plateau condyles is easiest with the knee in full extension. Flexion contractures can be a problem, and patients should be encouraged to regain/maintain knee extension. The dual-incision approach to these challenging fractures can result in good to excellent knee function for these patients.     

Fractures of the metacarpals: treatment by A. O. screw and plate fixation

Twenty-two patients with 26 fractured metacarpals were treated by internal fixation using A. O. mini-fragment screws and plates. This form of internal fixation was reserved for metacarpal fractures which were multiple, unstable, displaced or rotated. Nine patients had open fractures, two had divided extensor tendons and four had multiple fractures. Fractures consistently united without infection or deformity. The mean duration of postoperative immobilization was seven days and mean time off work was six weeks. All but one patient did manual work. No patients had persistent symptoms which caused difficulty with work or sport. Fourteen patients regained full movement. Four had total active movement of 220 degrees or more in the involved ray and 6 patients had total active movement of between 180 and 220 degrees. Restricted movement was present in patients with open fractures and divided extensor tendons or intra-articular fractures of the metacarpal head. Uniformly satisfactory results were found after mini-screw and plate fixation of metacarpal fractures.     

可吸收螺钉治疗儿童肱骨远端T形骨折

目的探讨可吸收螺钉治疗儿童肱骨经髁T形骨折的疗效。方法对7例儿童肱骨经髁T形骨折采用切开复位可吸收螺钉内固定,术后石膏托固定2-4周后进行功能锻炼。结果7例均得到随访,时间14-54个月。骨折全部愈合,时间1-4个月。采用改良的Morrey肘关节功能评分系统进行肘关节功能评价,并结合影像学检查结果,优2例,良4例,可1例。结论可吸收螺钉治疗儿童肱骨经髁T形骨折固定安全牢靠,疗效满意。