Suture-Button Fixation and Mini-Open Anterior Inferior Tibiofibular Ligament Augmentation Using Suture Tape for Tibiofibular Syndesmosis Injuries

Tibiofibular fixation using suture-button implants is an optional method for the surgical treatment of syndesmosis injuries. Although good clinical outcomes have been reported, inadequate stability between the tibia and fibula has also been documented. Thus, suture-button fixation is not considered the reference standard. For surgical treatment of lateral ligament injuries of the ankle, good treatment outcomes have also been reported with ligament augmentation using nonabsorbable suture tape. Ligament augmentation tape with suture-button fixation could also be promising for improved treatment outcomes in syndesmosis injuries. We describe suture-button fixation together with mini-open anterior inferior tibiofibular ligament augmentation using suture tape for treatment of syndesmosis injuries.     

Kreuzbandverletzungen bei offenen Wachstumsfugen

The surgical procedure for injuries of the anterior cruciate ligament (ACL) with an open epiphyseal growth plate has fundamentally changed in recent years. Although the indications for surgical reconstruction of the ACL after intraligamental rupture were in the past very reserved, the indications for operative treatment of osseous avulsion of the eminences were more clearly defined. The anatomically correct fixation of the avulsed osseous fragment leads to good up to very good results. The management of intraligamental tears of the ACL in cases of an open growth plate is still under discussion but in the literature there is a general trend towards operative treatment. In this article it is shown that relevant injuries of the growth plate are rare when an exact approach is used and are often related to technical failures.     

Diagnosis and treatment of the cruciate ligament injury of knee joint

During 1959 to 1986, 62 Cases with cruciate ligament injury of the knee joint were treated in our hospital. Thirty of these cases were anterior cruciate ligament injuries and 32 cases were posterior The diagnosis of the cruciate ligament injuries was made by stability tests of the cruciate ligament. When the knee was greatly swollen with multiple ligament injuries, a series of X-ray films should be taken to test the knee stability under local or nerve block anesthesia. Fresh tear of the cruciate ligament (33 cases) was treated with immediate surgical repair except in one. Old ligament injuries (28 cases) were treated by conservative method (10 cases) or surgical reconstruction (18 cases). All patients were followed for 2 to 18 years (mean 6 years). The results showed that the fresh tear of the cruciate ligament treated surgically had excellent and good rates in 87.9% (29/33). In the conservative treatment group, only 27.3% (3/11) obtained good result, and most of them were complicated with meniscal lesions and osteoarthritis. Eighteen cases treated by ligament reconstruction gave 34.5% (8/18) good result.     

Rekonstruktion des vorderen Kreuzbandes

The treatment of ruptures of the anterior cruciate ligament (ACL) plays an essential role for both clinicians and resident physicians. To date many questions regarding the outcome as well as ACL reconstruction techniques have not yet been conclusively clarified. Whether reconstruction of the ACL protects the knee from osteoarthritis is still unproven; however, it is well known that an unstable knee joint is more vulnerable to secondary injuries, such as meniscal tears. Thus, early ACL reconstruction is recommended to minimize the risk of these secondary injuries. Three alternative sources of material for autologous ACL reconstruction are commonly utilized. An accessory hamstring (i.e. semitendinosus tendon with or without the gracilis tendon), a central strip of the patellar tendon with bone blocks and a central strip of the quadriceps tendon with or without bone block are the most common donor tissues used in autografts. Besides selection of the type of graft, the tendon diameter also plays a crucial role. Some progress has recently been made with respect to tunnel placement. The aim is to find an anatomical tunnel position. Reconstruction of both the anteromedial and the posterolateral ACL bundles helps to rebuild the anatomy of the original ACL; however, scientifically this approach did not lead to any improvement in the results. For fixation techniques a differentiation is made between aperture, extracortical and implant-free fixation. Generally, re-ruptures are less common than revisions as a result of graft ruptures due to technical mistakes during surgery. The most common mistakes concern tunnel placement and graft fixation. Also overlooked instability can have a negative influence on the outcome of ACL reconstruction.     

Kollateralbandverletzungen der Fingergrundgelenke

Collateral ligament injuries of the metacarpal joints of the fingers are rare conditions. The injury should be diagnosed by clinical investigation and standard radiographs. Leading symptoms are local tenderness and joint instability. Instability is verified by clinical stress testing of the metacarpophalangeal joint in 90° of flexion. In Grade I injuries stability is preserved due to ligament attenuation or small partial tears. Grade II injuries show laxity with firm endpoint according to incomplete tear. In Grade III injuries instability without endpoint can be found as a result of complete tears. Radiographs may show avulsed bone fragments.In Grade I and II tears or non- displaced avulsion fragments treatment is conservative with buddy taping for 6 weeks. In case of persistent instability or grade III tears suturing or refixation of the ligament are performed. Small avulsion fragments are removed and the ligament is fixed to the bone. Greater avulsion fragments are fixed by suitable small implants. Adequate treatment will lead to reliable good results. Even in chronic tears reconstruction with local material or tendon transplants is usually successful.     

Coronoid plate fixation of type II and III coronoid process fractures: outcome and prognostic factors

The purpose of the present study was to determine the clinical outcome and prognostic factors after applying the coronoid plate fixation technique who had sustained type II or III coronoid process fractures. Fifteen consecutive patients were enrolled in this study. The mean arc of flexion–extension was 116° with a mean flexion and flexion contracture of 126° and 11°, respectively. The mean arc of forearm rotation was 158° with a mean pronation and supination of 78° and 80°, respectively. The mean Mayo Elbow Performance Score (MEPS) was 88 points (range, 70–100 points), which corresponded to an excellent result in ten elbows, good result in four and fair result in one. All the isolated coronoid fractures (8 patients) (there was no combined injury) and nine of the eleven (82%) noncomminuted coronoid fractures (the existence of one or two fracture fragments) had excellent functional results in accordance with the MEPS (average MEPS was 93.8 and 93.3, respectively). Patients with less favorable results according to the MEPS had lateral side injuries, such as lateral collateral ligament injures or radial head fractures (mean MEPS 78.0) The average functional score (MEPS) of the patients showing signs of arthritic changes was 76.7. Based on our experience, coronoid plate fixation of type II and III coronoid process fractures is an acceptable and alternative method that can provide good results. However, acceptable clinical outcomes are not only related to the successful rigid internal fixation of the coronoid fracture but depend on the severity of the primary injury and associated soft tissue injuries. The comminution of the fracture fragment, associated lateral collateral ligament injuries, and posttraumatic arthritic changes can be considered indicators of a poor functional outcome.     

Rupturen der tibiofibularen Syndesmose

The standard treatment of distal ruptures of the tibiofibular syndesmosis is an anatomical reduction of the fibula and fixation with one or two tibiofibular syndesmosis screws. The incidence of isolated distal rupture of the tibiofibular syndesmosis is rare. On the other hand 1 in 10 fractures of the ankle is associated with a relevant syndesmotic instability. The classification of Lauge Hansen is based on the analysis of the pathomechanism. A correct reduction and positioning of the screws is mandatory for a good clinical result. Injuries of the ankle combined with syndesmotic instability lead to worse outcome than those without, even after surgical treatment. This can be explained by many reasons, especially by the severity of the injuries but also by the quality of reduction and fixation. The syndesmosis screw fixation method is presented as a standard fixation and additionally the Ankle TightRope? is described as a valid treatment alternative.     

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.     

Functional and radiological outcome after arthroscopic and open acromioclavicular stabilization using a double-button fixation system

The aim of this study was to determine the functional outcome and radiological results after open and arthroscopic stabilization of the acromioclavicular joint using a double-button fixation system. We reviewed 16 patients that were surgically treated for acromioclavicular dislocation using a double-button fixation system. An arthroscopic technique was used in 9 patients for acute injuries and an open technique in 7 patients for subacute or chronic lesions. Mean follow-up was 17 months (range : 6-26 months). The mean DASH score post-operatively was 2.29 (range : 0-5.83), VAS score was 0.82 (range : 0-2) and SSV averaged 90.5 % (range: 80-95%). Radiologically the reduction of the acromioclavicular joint was complete in 10 patients. A clinically stable residual subluxation was present in 5 patients. Only one patient experienced a redislocation after new trauma and needed revision surgery. Operative treatment of grade 3 and 4 acromioclavicular dislocations, using a double button coracoclavicular fixation system, yielded good functional results with full return to work and recreational activities. Arthroscopic coracoclavicular fixation without CA ligament transfer should be reserved for acute injuries within 2 weeks after the trauma.     

Ligamentäre Kniegelenkverletzungen im Wachstumsalter

Due to an increase in sporting activities, the number of injuries of the immature knee is continuously increasing. These injuries necessitate a special approach regarding the particular anatomical situation with open growth plates. Three of the most commonly occurring injuries are rupture of the anterior cruciate ligament, patella dislocation and meniscus injuries. The clinical results for conservative treatment of ruptures of the anterior cruciate ligament in the growth phase are inferior to operative treatment. Transepiphyseal reconstruction has been shown to be a safe treatment method and provides good clinical results. Therapy of patella instability in children has shown poor results and new surgical techniques have been introduced to perform an anatomical reconstruction of the medial patellofemoral ligament as well as to improve distal alignment. Isolated injuries to the meniscus are rare and discoid meniscus is a special phenomenon occurring in infancy. Meniscus injuries should be treated with primary sutures rather than resection. A discoid meniscus should be resected with extreme caution and anatomically reconstructed.     

Akute mediale Seitenbandverletzung am Kniegelenk

The medial collateral ligament complex (MCL) is the most commonly damaged ligamentous stabilizer of the human knee. The diagnostic algorithm comprises patient history, clinical examination and magnetic resonance imaging (MRI). It is important to distinguish between incomplete and complete ruptures of the MCL. For adequate treatment the classification and exact knowledge about concomitant injuries are important. A nonoperative treatment of incomplete ruptures (grades I and II) is widely accepted and usually results in a good clinical outcome but the treatment of complete ruptures (grade III) is a subject of controversy. Complete intraligamentous ruptures with a correct approximation of the stumps and intact dorsomedial joint capsule can also be treated nonoperatively with good and excellent results. In contrast, ruptures close to the abutment and bony avulsions tend to heal better through operative treatment. Dehiscence or dislocation of the ligament stumps in MRI is an indication for operative treatment. In the context of a multiligamentous injury or complex instability, the majority of authors suggest an operative stabilization. As the treatment of chronic instability can be challenging, the initial and adequate treatment of acute ruptures is of great importance.     

Displaced, unstable fractures of the radial head: fixation vs. replacement--what is the evidence?

Unstable, displaced fractures of the radial head nearly always occur in association with other fractures or ligament injuries. Radiocapitellar contact is important to elbow and forearm stability and should be restored in the context of such injuries. Open reduction and internal fixation of the radial head is associated with early failure, nonunion, and poor forearm motion. Replacement of the radial head with a metal prosthesis may be preferable. The major pitfall of a metal prosthesis is insertion of a prosthesis that is too large in longitudinal length, which can lead to subluxation, capitellar wear, stiffness, and pain. When this is avoided the medium- and long-term results are satisfactory with no major problems identified.     

Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures

BACKGROUND: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome. METHODS: We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and in selected cases repair of the medial collateral ligament and/or adjuvant hinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up. RESULTS: At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112 degrees +/- 11 degrees and forearm rotation averaged 136 degrees +/- 16 degrees. The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a wound infection. CONCLUSIONS: Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.     

Wrist: Current Diagnosis and Treatment of Scaphoid Fractures and Injuries of the Scapholunate Ligament

Summary BACKGROUND: Fractures of the scaphoid and injuries to the scapholunate ligament are mostly seen as causes of the acute and chronic painful wrist. Strict guidelines are necessary to precisely detect these lesions in the acute stage and to provide adequate treatment. A computed tomography bone scan parallel to the long axis of the scaphoid is best for demonstrating fractures and any associated deformities. Scapholunate ligament injuries are best staged by standard plane radiographs including stress views and by arthroscopy of the wrist. METHODS: To avoid lengthy plaster immobilization and to lower the risk of nonunion, displaced and comminuted scaphoid fractures of the wrist as well as all proximal pole fractures should be internally fixed. Headless screws such as the Herbert screw, now available in a cannulated shape, allow the minimally invasive stabilization of the majority of these fractures with a high success rate under early mobilization. Undisplaced fractures can be treated conservatively with a below-elbow cast; alternatively, they can be stabilized percutaneously without the need for immobilization in a cast. Early diagnosis of scapholunate ligament injuries is most important, as anatomical healing of the injured ligaments can be expected only with primary treatment including correct realignment of the scaphoid and lunate followed by immobilization in a cast for about 8 weeks. In cases of chronic lesions, ligament reconstruction or even partial wrist fusion can be performed. In order to assess the different procedures, precise classification and staging with regard to a dynamic or static pattern are needed. RESULTS: Early rigid fixation of scaphoid fractures promotes a union rate of up to 100 % with rapid functional recovery. Primary repair of scapholunate ligament injuries provides the best clinical outcome. Ligament reconstruction or partial wrist fusion can help to prevent rapid secondary arthrotic changes in the wrist and leads to significant pain relief, however with restriction of mobility and grip strength. CONCLUSIONS: Standardized diagnosis and treatment of scaphoid fractures and scapholunate ligament injuries improve clinical outcome and significantly reduce post-traumatic arthrotic changes in the wrist.     

Conservative Treatment for the Intraoperative Detachment of Medial Collateral Ligament from the Tibial Attachment Site during Primary Total Knee Arthroplasty

For intraoperative injuries of the medial collateral ligament (MCL) during primary total knee arthroplasty (TKA), many authors recommended complex reconstructive procedures or conversion to the constrained prosthesis in previous literature. However, it is well known that medial collateral ligament has good healing potential after injuries. This retrospective study evaluated the clinical and radiological results of 15 primary TKAs complicated with intraoperative complete detachment of the MCL from tibial attachment site, which were all treated solely by nonoperative conservative treatment without any other additive procedures or braces. Compared to the MCL-intact contralateral knees, there was no significant difference in terms of clinical and radiological outcome at minimum of 2 postoperative year. There was no case showing clinical instability, either. Solely, the nonoperative conservative treatment for intraoperative injuries of the MCL during primary TKAs is expected not only to be effective with satisfactory results but also to decrease complications derived from other sophisticated reparative or reconstructive procedures.     

Endoprothetik der akuten Radiuskopffraktur

Radial head arthroplasty is the treatment of choice for non-reconstructble radial head fractures. Solid prostheses made of metal or pyocarbon can restore valgus stability of the elbow independent of design or stem fixation. Short-term and mid-term results show mostly good to excellent results without any evident differences between the different prosthesis philosophies. In ordert to obtain good results it is important to implant the prosthesis correctly without overfilling and to judge concomitant ligament injuries correctly. This article discusses the anatomical and biomechanical basis of radial head arthroplasty as well as the surgical technique and radiological diagnosis of overfilling.     

髌腱及股四头肌腱断裂的诊断与治疗

目的：探讨髌腱及股四头肌腱断裂的诊断与治疗问题。方法：23例髌腱及股四头肌腱断裂的患者。股四头肌或股四头肌腱断裂12例（急性股四头肌或股四头肌腱损伤7例,陈旧性股四头肌或股四头肌腱损伤5例）。髌腱断裂11例（急性髌腱损伤共8例,陈旧性髌腱损伤共3例）。回顾性统计患者的年龄、致伤原因、损伤性质、症状、体征、辅助检查、受伤至手术时间间隔、手术治疗方式、制动情况、膝关节活动度、功能恢复情况（采用Lysholm评分。积分达95分以上者为优秀,94-85分为良好,84-65分为尚可,小于65分为差）、髌骨位置高低（Insall方法）及满意程度。结果：23例髌腱及股四头肌腱断裂患者平均随访期为6年（4个月-11年6个月）。3例因联系方式失效而失访。急性股四头肌或肌腱断裂急诊修复者5例优秀,2例良可。急性髌腱断裂急诊修复8例均为优秀。陈旧性股四头肌及股四头肌腱损伤5例,2例为优秀（3例失访）。陈旧性髌腱断裂重建结果为优秀1例,优良2例。结论：手术治疗髌腱及股四头肌腱断裂,急性髌腱及股四头肌腱断裂早期修复有很好的预后。陈旧性损伤的预后劣于急性髌腱及股四头肌腱断裂早期修复,但经过治疗亦可取得较为满意的结果。     

Functional outcome of arthroscopic assisted fixation of distal radius fractures

Background:

Many studies in literature have supported the role of wrist arthroscopy as an adjunct to the stable fixation of unstable intraarticular distal radial fractures. This article focuses on the surgical technique, indications, advantages, and results using wrist arthroscopy to assess articular reduction and evaluates the treatment of carpal ligament injuries and triangular fibrocartilage complex (TFCC) injuries in conjunction with the stable fixation of distal radial fractures.

Materials and Methods:

We retrospectively evaluated 27 patients (16 males and 11 females), who underwent stable fixation of intraarticular distal radial fractures with arthroscopic evaluation of the articular reduction and repair of associated carpal injuries. As per the AO classification, they were 9 C 1, 12 C2, 2 C3, 3 B 1, and 1 B2 fractures. The final results were evaluated by modified Mayo wrist scoring system. The average age was 41 years (range: 18-68 years). The average followup was of 26 months (range 24-52 months).

Results:

Five patients needed modification of the reduction and fixation after arthroscopic joint evaluation. Associated ligament lesions found during the wrist arthroscopy were TFCC tears (n=17), scapholunate ligament injury (n=8), and luno-triquetral ligament injury (n=1). Five patients had combined injuries i.e. included TFCC tear, scapholunate and/or lunotriquetral ligament tear. There were 20 excellent, 3 good, and 4 fair results using this score.

Conclusion:

The radiocarpal and mid carpal arthroscopy is a useful adjunct to stable fixation of distal radial fractures.     

Surgical and nonsurgical treatment of acute ankle sprains

In the treatment of eversion injuries or tears of the medial structures, exact anatomic restoration is mandatory, and this must be accomplished by either closed reduction or surgery. The treatment of lateral ankle ligament injuries is usually cast immobilization, taping, or a cast-brace. Surgical treatment of lateral ankle ligament sprains is performed only on those highly competitive young individuals who require an almost normally functioning ankle.