Minimalinvasive Schultereckgelenkstabilisierung mit freiem Sehnentransplantat

Revision surgery following unsuccessful acromioclavicular (AC) joint stabilization and chronic joint instability presents a great challenge in orthopedics. In those cases, sufficient healing of the coracoclavicular (CC) ligaments cannot be expected. Different kinds of procedures are described for the operative treatment of chronic AC joint instability that can be divided into anatomic and non-anatomic techniques. The basic idea is to provide stability and a biological basis for the ligamentization process of the CC ligaments. The anatomic, minimally invasive operation techniques using TightRope? or similar pulley systems in combination with a free tendon autograft have turned to a widely accepted and used treatment for chronic acromioclavicular (AC) joint separations.     

Editorial Commentary: Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction Leads to Improved Patient-Reported Outcomes,But Patient Satisfaction Is a Harder Threshold to PASS

There are numerous described techniques for surgical management of high-grade acromioclavicular (AC) joint injuries, and the associated clinical outcomes can be quite variable. Contemporary techniques are typically directed at anatomic reconstruction of the coracoclavicular (CC) ligaments through either an arthroscopy-assisted or an open approach. Most patients treated with acute surgery improve, whereas in chronic cases, the majority improve, but a significant number have persistent recurrent deformity due to loss of anatomic reduction. In addition, whether acute or chronic, over one quarter of patients do not have a PASS (patient acceptable symptomatic state). Of interest, PASS may not primarily be related to the final deformity in terms of coracoclavicular distance, and investigation is still required in terms of the effect of anteroposterior or rotational instability of the AC joint after injury and surgery. Finally, PASS values for AC separation are not well established, resulting in a current limitation of the strength of applying threshold values to this pathology.     

Akute Sprengung des Akromioklavikulargelenks

Dislocation of the acromioclavicular joint (AC joint) is a typical sports injury with rupture of the acromioclavicular and coracoclavicular ligaments which may result in a vertical and horizontal instability of the lateral clavicle. Stress X-rays may be of help for the diagnosis of vertical instability and for the diagnostics axial or Alexander views should be made. In the future magnetic resonance imaging (MRI) will play a significant role for the diagnostics of AC joint injuries. With this method injuries of ligaments, fascia and the glenohumeral joint can be diagnosed. There is controversy regarding the therapy of AC joint injuries. For slight injuries a conservative treatment is recommended, for medium degree instability there is too little evidence in the literature to give a clear recommendation whether conservative or operative treatment is superior and for severe instability an operative treatment is recommended. For operative treatment several techniques have been described. Some techniques have a high complication rate and implant removal is also disadvantageous. These disadvantages led to the development of minimally invasive or arthroscopic techniques. The first clinical results of these new techniques are encouraging.     

Revisionen und Salvage-Procedures nach Verletzungen des Akromioklavikulargelenks

Failed conservative treatment or surgical procedures for acute AC joint seperations create the demand for revision or salvage procedures to successfully treat persistent AC joint instability. Besides the classic Weaver-Dunn procedure and its modifications lately new procedures combining a more or less rigid implant for primary stability with a biologic augmentation using an autologous tendon graft have been developed. These procedures are performed arthroscopically or arthroscopically assisted.     

Arthroskopisch gestützte Techniken zur Versorgung der akuten und chronischen AC-Gelenk-Verletzung

Acute and chronic acromioclavicular (AC) joint dislocation is frequently encountered in the routine clinical practice. This injury can lead to significant impairment of shoulder girdle function. Therapy based on the severity of injury is recommended to re-establish correct shoulder function. The static radiographic Rockwood classification is used to define the degree of dislocation but the clinical aspects and functional x-ray imaging of horizontal AC joint instability should also be considered for selection of the appropriate procedure. Rockwood grades I and II injuries are treated non-operatively with early functional exercise. The approach for Rockwood grade III injuries should be individual and patient-specific, with non-surgical procedures for low functional requirement patients with a high risk for surgical interventions. For patients with high demands on shoulder function surgery is recommended. A detailed diagnostic assessment frequently reveals Rockwood grade III injuries to be type IV injuries. Rockwood types IV and V AC joint dislocations require surgery for sustained stability. Treatment of acute injuries is recommended within 1-3 weeks after trauma but there is no clear evidence of a cut-off for the presence of chronic injuries. Various surgical techniques have been described in the literature. This article presents an arthroscopically assisted technique that addresses both vertical and horizontal instability of the AC joint.     

Instabilitätsmuster bei Akromioklavikulargelenkverletzungen vom Typ Rockwood III

Background

There is no evidence-based treatment algorithm established for acromioclavicular joint (AC joint) dislocation classified as type Rockwood III injury. Recent meta-analyses revealed no advantage of surgical treatment compared to the non-operative approach. Both surgical and non-surgical approaches have been reported with inconsistent results. Therefore, the hypothesis of the current study was that patients classified as having Rockwood grade III injury may have different degrees of horizontal AC joint instability.

Material and methods

A total of 18 consecutive patients who had sustained a dislocation of the AC joint classified as Rockwood III were evaluated radiologically to quantify the horizontal instability of the AC joint. The specific radiological investigation included lateral stress x-rays (Alexander view) und axial stress x-rays with the affected arm in a horizontal adduction position.

Results

The dynamic horizontal instability of the AC joint was found to be independent of the vertical dislocation measured in the Rockwood classification.

Conclusion

For further treatment studies Rockwood III injuries should be distinguished in patients presenting with or without a substantial horizontal AC joint instability.     

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.     

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.     

Editorial Commentary: Why We Have To Respect The Anatomy In Acromioclavicular Joint Surgery And Why Clinical Shoulder Scores Might Not Give Us The Information We Need!

Over the past decade, the interest in acromioclavicular (AC) joint research has experienced a revolutionary increase. Biomechanical and anatomic studies have been carried out to investigate and obtain a better understanding of the function of this joint. The reason for this huge investigational effort is the fact that we do not have any gold standard for the treatment, diagnosis, or follow-up of patients with acute or chronic AC joint injuries. This is reflected by the huge number of over 160 different surgical techniques described in the literature. So far, we have a variety of anatomic procedures, nonanatomic procedures, and nonanatomic procedures with open reduction and internal fixation, with a significantly better clinical outcome for anatomic techniques. Because of this wide variety, it is hard and nearly impossible to compare clinical data. Within the past 5 years, we have focused not only on the vertical instability but also, more and more, on the horizontal instability and tried to understand the rotational component of this joint with the importance of scapulothoracic motion. The evolutionary advantage of bipedalism with the support of the clavicle compared with quadrupedalism allows us to lift our arms for overhead activities. Therefore, we need an intact sternoclavicular and AC force transfer, described as the “strut function,” to give a resistance against the thorax when abducting the arm over 90°. Once we have an interruption in this force transfer, we believe that it is the most important aspect in AC joint surgery to try to anatomically restore this joint's anatomy. For this reason, we have changed our practice in the past few years in line with the newly derived data, by addressing the coracoclavicular ligaments as well as the AC capsule to restore horizontal and vertical stability but also allow for physiological rotation and movement.     

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.     

Traumatic injuries of the distal radioulnar joint

Traumatic injuries of the distal radioulnar joint (DRUJ) may give rise to complex wrist pathologies. Substantial ongoing disability can arise should these injuries go unrecognized resulting in sub-optimal treatment and lack of appropriate rehabilitation. Injuries of the DRUJ may occur in isolation but more commonly are found with a fracture of the radius. These challenging DRUJ injuries may be simple or complex (irreducible or severe instability), acute or chronic. An adequate knowledge of the stabilizers of the DRUJ is essential in understanding treatment options. Traumatic instability of the DRUJ is reviewed and the anatomy and stabilizing factors are discussed. An algorithm to guide selection of treatment options in complex cases is presented.     

Epidemiologie, Anatomie, Biomechanik und Bildgebung von Akromioklavikulargelenkverletzungen

Current techniques of acromioclavicular (AC) joint repair primarily focus on the reconstruction of the coracoclavicular (CC) ligaments. However, it is not clear if this approach is sufficient to restore vertical as well as horizontal AC joint stability and kinematics. This review focuses on the epidemiology of AC joint injuries and the coincidence of intra-articular pathologies. Furthermore, the clinically relevant anatomy and the pathomechanism of AC joint instability are described. The biomechanical characteristics of current procedures as they have been revealed by in vitro investigations are summarized. As a basic result, neither selective repair of the CC ligaments nor selective repair of the AC ligaments could be shown to restore both vertical and horizontal joint stability. Similar to the intact ligaments CC repair primarily provides vertical joint stability while AC repair is able to restore horizontal stability. In conclusion a biomechanically effective treatment of AC joint separation should analyze the individual instability pattern in the first step. Therefore, the radiological standard according to Rockwood should be supplemented by specific stress x-rays for quantification of dynamic horizontal AC joint instability. In the second step an adequate surgical treatment considering CC and AC stabilization should be performed meeting the individual patient requirements.     

Palmar radiocarpal dislocation resulting in ulnar radiocarpal translocation and multidirectional instability

Posttraumatic ulnar radiocarpal translation is a rare, often subtle, highly unstable, and potentially devastating manifestation of severe "proximal radiocarpal ligamentous instability. Radiocarpal dislocation should alert the treating physician to the risks of the spectrum of radiocarpal instabilities. Radiocarpal instability may initially be masked or unappreciated owing to presentation without radiocarpal dislocation, local pain and swelling, initially normal standard wrist radiographs, lack of recognition, or delay in the appearance of a static lesion. The specificity, sequence, and extent of extrinsic radiocarpal and ulnocarpal ligament traumatic disruptions are not fully understood, vary with injury severity, and may differ in instances of dorsal as opposed to palmar subluxation or dislocation. Multidirectional (global) wrist instability typically accompanies this ulnar radiocarpal instability in its most severe form and consequences may be dire. The carpus may be difficult to reduce or maintain owing to marked instability, compressive forces across the wrist, and soft tissue or bony fragment interposition. Additional local distal radioulnar joint or intercarpal injuries may further confound stability and require their own specific and simultaneous treatment. Radiocarpal reduction and repair of the radioscaphocapitate ligament and radiolunate ligaments may be sufficient treatment for acute isolated palmar radiocarpal instability. Temporary K-wire fixation may be added as a precaution to prevent palmar carpal subluxation during the time of ligament healing. Radiocarpal reduction, palmar and dorsal soft-tissue repair, and temporary K-wire fixation comprise one method of treatment for early recognized cases of post-traumatic ligamentous ulnar radiocarpal transposition. Halikis et al have recommended radiolunate arthrodesis. Rayhack et al have suggested that limited or complete wrist arthrodesis may be indicated for patients with delayed presentation or in acute cases with extreme instability. Wrist arthrodesis is one means of management for patients with severe radiocarpal instability confounded by distal radioulnar joint or intercarpal instability, as seen in our patient. Damaged ligaments may have a poor blood supply and often may not hold sutures or heal well. Bone anchor sutures or some type of ligament augmentation may help to restore joint stability in some patients. Loss of stability may occur later owing to ligamentous laxity or inadequate soft-tissue healing. Radiolunate, radiocarpal, or complete wrist arthrodesis may be necessary to relieve pain, restore wrist alignment and stability, and reestablish extremity function for patients with chronic radiocarpal instability. Wrist symptoms, age, general health, hand dominance, and occupation may be among the factors that influence the necessity for and timing of reconstruction. Rayhack et al have also postulated that negative ulnar variance may accommodate the occurrence of ulnar radiocarpal translocation and confound repair owing to lack of buttress at the ulnocarpal joint. They further speculated that a joint leveling procedure might improve the support for ligamentous repair or reconstruction in these cases. Permanent functional impairment must be anticipated in patients with ulnar radiocarpal instability. Impairment has typically been commensurate with the extent of the initial lesion, additional confounding local lesions, and length of follow-up.     

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.     

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.     

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.     

Lisfranc fracture-dislocations: current treatment and new surgical approaches

Anatomic reduction and restoration of the acute or chronic fracture-dislocation of the tarso-metatarsal joint is essential and needs to be addressed early in the patient's treatment with internal or external fixation. Long-term results following this injury can be associated with chronic instability, posttraumatic arthrosis, and poor functional outcomes. In this article, the authors review the current treatments of internal fixation and introduce new surgical techniques for addressing the acute or chronic tarso-metatarsal injuries with the application of circular multiplane external fixation devices.     

Dislocations and fracture dislocations of the metacarpophalangeal joint of the thumb

Due to its exposed position, the MCP joint of the thumb is particularly vulnerable to dislocations and fracture dislocations. Depending on the direction of the injuring force, injuries to the ulnar, radial, and volar aspect of the joint can occur. If high-grade lesions are not identified and treated appropriately during their acute phase, marked instability with associated long-term disability due to weakness and pain in pinch and grip can result. In the absence of a reliable method for diagnosing the Stener lesion, surgical repair of acute, third-degree lesions on the ulnar side of the joint remains the treatment of choice. In the presence of chronic instability, a variety of effective soft tissue reconstructive measures are available. The fact that both acute and chronic injuries enjoy a favorable prognosis with operative repair is due to the fact that operative intervention reliably restores stability to the joint. Mild to moderate loss of motion at the joint is well tolerated functionally. For this reason, arthrodesis remains an exceptionally satisfactory salvage for failed soft tissue reconstructions.