Search

In 1997 six patients with posttraumatic ankle arthritis aged 54 (45-71) years were treated with a LINK S.T.A.R. ankle prothesis. The average follow up was 29 (21-36) months. Results were evaluated according to the ankle score of H. Kofoed [7]. Two patients had an excellent outcome and 1 patient had a fair result. In three patients secondary arthrodesis had to be performed, due to loosening of the implant. Based on our experiences we cannot recommend this implant for patients with posttraumatic arthritis at this time.

Forty-four patients who had undergone unilateral anterior cruciate ligament reconstructions were evaluated retrospectively with seven different scoring systems (International Knee Documentation Committee, Orthopadische Arbeitsgruppe Knie, Lysholm, Feagin and Blake, Zarins and Rowe, Cincinnati, and Marshall scores). The results varied between systems and therefore lacked reliability. Of the 44 patients, 32 were rated as excellent according to the Cincinnati score while only 3 patients were rated as normal according to the International Knee Documentation Committee form. Good and excellent results were found twice as frequently with the Cincinnati and Lysholm scores compared with the scores of Zarins and Rowe or the International Knee Documentation Committee form. Statistical analysis confirmed this observation and revealed significant differences between the scoring systems. Side-to-side differences using the manual maximum displacement test with the KT-1000 arthrometer revealed good correlation with the International Knee Documentation Committee and the Orthopadische Arbeitsgruppe Knie questionnaires. None of the other scoring systems, which do not measure anterior laxity, produced reasonable correlation with instrumented measurements. We found that certain population-specific factors as well as the distribution of single findings can distort the results of scoring systems. To avoid these interference factors, the patient sample should be homogeneous and selected prospectively and there should be agreement about the value of single findings.

Background: From 1992 through 1997 96 patients with per- or subtrochanteric femur fractures were treated with a Gamma nail. We retrospectively evaluated the influence of patient age, additional diseases, type of fracture, time of operation, type of implant (short/long Gamma nail) and surgical approach (open/closed reduction) on the mobility of the patients, healing of the fractures on radiographs, and possible complications., Patients and Methods: The average patient age was 72.5 years (range 27 to 101). There were 27 male and 69 female patients. Surgery was performed 1.19 (0-10) days after injury. At 3, 6, and 12 months after surgery radiographs of the involved hip joint and femur were obtained and the degree of mobility was assessed., Results: Additional diseases, type of fracture, time of operation, type of implant (short/long Gamma nail) and surgical approach (open/closed reduction) did not influence mobility of the patients, healing of the fractures on radiographs or rate of complications. It was more difficult to mobilize older patients (P < 0.001). After 1 year 97% of all fractures had healed on radiographs. In 15 patients (18%) complications occurred due to technical errors using the Gamma nail., Discussion: With the Gamma nail stable osteosynthesis of per- and subtrochanteric femur fractures is obtained independently of the fracture classification. Patients can be mobilized immediately. Technical errors must be avoided.

We treated 13 elite rock climbers for isolated disruptions of the pulleys of the long fingers. Diagnosis and treatment were based on the clinical finding of bow-stringing, which was confirmed by magnetic resonance imaging. Eight patients had bowstringing indicating incomplete disruption of the major pulley A2 and were treated nonoperatively (group A). Five patients showed bowstringing indicating complete disruption of the pulley A2. After failed nonoperative treatment, the pulleys were reconstructed (group B). The mechanism of injury and clinical and subjective results were evaluated. At a 31-month follow-up (range, 18 to 43 months), loss of extension in the proximal interphalangeal joint measured 5.6 degrees (range, 0 degree to 10 degrees) in group A and 4 degrees (range, 0 degree to 10 degrees) in group B. Circumference of the finger section was increased 4.2 mm in group A (range, 0 to 10 mm) and 4.8 mm in group B (range, 0 to 10 mm). Grip strength decreased 20 N in group A (range, 10 to 50 N) and 12 N in group B (range, 10 to 30 N). Four patients in group A and one in group B had bowstringing at clinical evaluation. On follow-up magnetic resonance images, bowstringing remained unchanged in group A but was reduced in all patients in group B. Good subjective results were seen in both groups.

We evaluated the histopathologic and cryosectional appearance of bone bruise injuries of the knee detected on MRI. Histologic evaluation of bone biopsies from 3 patients revealed microfractures of cancellous bone, edema and bleeding in the fatty marrow. Between intact lamellar bone trabecules, fragments of hyaline cartilage mixed with highly fragmented bone trabecules were found. Postmortem specimens were obtained from 2 more patients, killed in motor vehicle accidents. MRI revealed bone bruise injuries of the lateral femoral condyle and of the lateral tibial plateau in 1 knee and anterior cruciate ligament disruption, a medial meniscus tear and bone bruise injury of the tibial plateau and of the lateral femoral condyle in the other specimen. The specimens were embedded in physiologic saline solution and frozen to -30 degrees C. By rotationcryotomy, 1 mm slices were removed from the surface of the specimens and documented on photographs. Subchondral lesions and bleeding were found, corresponding to the MR images.

Sixty-three patients with humeral shaft fractures were evaluated clinically and radiographically 18 months after injury; 27 patients were treated surgically (group A) and 36 patients conservatively (group B). Analysis of the results according to a score by Kwasny revealed 6.2 points in group A and 2.2 points in group B (P < 0.0001; F = 46.9). The results of these two comparable groups suggest that conservative treatment of humeral shaft fractures is superior regarding mobility of the shoulder and elbow, strength, the incidence of neurological complications, pain, subjective rating and cosmesis. There were no differences on roentgenograms between the two groups (P = 0.48).

The biphasic ultrastructure of the meniscus and of articular cartilage provides their function in the complex biomechanics of the knee joint including load distribution, shock absorption, viscoelasticity, a smooth low friction gliding surface and resilience to compression. Meniscectomy may lead to destruction of cartilage and to osteoarthritis of the knee joint. Osteoarthritic changes after meniscectomy have been reported in up to 89% of patients. Retrospective analysis after open or arthroscopically assisted meniscectomy revealed restriction in sports to be between 2 and 50% and cessation of sports to be between 2 and 25%. Generally, patients with degenerative changes at the time of surgery are reported to have lower knee joint function and to resume sports activities later. Pharmalogical measures to treat osteoarthritis following previous meniscectomy include pain medication and intra-articular drug administration. Additionally, range of motion and strengthening exercises and moderate athletic activities are recommended. When surgery is considered, correctional osteomies and unicompartmental or total knee arthroplasty depending on the degree of osteoarthritis are preferred.

Eighty-five patients with grade 2 or grade 3 sprains of the acromioclavicular (AC) joint were evaluated clinically and radiographically 32 months after injury. Group I included 34 patients with grade 2 sprains (Tossy II) and group II included 51 patients with grade 3 injuries (Tossy III). In group I, 15 patients were treated surgically (group Ia) and 19 patients were treated conservatively (group Ib), while in group II, 41 patients were treated surgically (group IIa) and 10 patients were treated conservatively (group IIb). At surgery open reduction and transarticular fixation of the AC joint with Kirschner wires was performed. Conservative treatment included the initial use of a sling or a knapsack bandage and early performance of range-of-motion exercises. Shoulder function was assessed according to the score devised by Constant and Murley. In both groups, 97 of 100 possible points (minimum 72, maximum 100) were obtained after conservative and after surgical treatment. Nine of 10 patients (90%) with grade 3 sprains (group IIb) had more pronounced displacement and increased mobility of the lateral end of the clavicle after conservative treatment. After surgery, dislocation and increased horizontal, mobility of the lateral end of the clavicle occurred in 18 (44%) of 41 patients with grade 3 sprains (group IIa P < 0.0001). However, these findings did not correlate with the functional outcome. At follow-up there was a significant increase in degenerative changes seen on radiographs (P < 0.035) in all patients. Again these findings did not correlate with the functional outcome. More degenerative radiological changes were observed in patients who had undergone surgery (P < 0.003). Patients with grade 2 sprains were more frequently restricted in sporting activity after surgery (P < 0.05). Patients with grade 3 sprains who were treated surgically complained of pain more frequently (P < 0.01), and they returned to work later than patients who were treated conservatively after grade 3 sprains. An additional rehabilitation program guided by a physiotherapist seemed to have no impact on the functional outcome. A total of 56 patients were treated by surgery. Among these patients 11 complications occurred, requiring five additional surgical procedures. Among 29 conservatively treated patients, only in 1 patient did subacromially located arthritic changes of the AC joint have to be removed.

In a prospective study, magnetic resonance imaging was performed before arthroscopy for all patients (n = 121) with a meniscal tear (n = 125). Criteria of the study were stable cruciate and collateral ligaments, absence of pathologic radiographic findings, and absence of prior surgical interventions of the involved knee joint. In 43 knees (34%), the clinical diagnosis of a meniscal tear was discarded because of the results of the magnetic resonance imaging examination. Synovitis was diagnosed in 16 patients (13%), articular cartilage damage in 10 patients (8%), bone bruise injuries in 10 patients (8%), osteochondritis dissecans in 3 patients (2%), disruption of the inner layer of the medial collateral ligament in 3 patients (2%), and osteonecrosis in 1 patient. The use of magnetic resonance imaging in establishing diagnosis of disorders of the knee joint altered treatment in a significant proportion of patients. Magnetic resonance imaging should be done before arthroscopy of the knee in all cases in which the clinical diagnosis has been reduced to a suspected meniscus injury.

A solid AO unreamed tibial nail was found to be broken at the revision operation for a pseudoarthrosis following open tibial fracture treatment in a 17-year-old girl. The nail breakage had not been detectable in the roentgenograms. Access to the broken nail was achieved through a longitudinal osteotomy via the tibial tuberosity. A metal drill was used to drill a 5-mm hole proximally into the medial aspect of the nail. There the tip of an elevatorium could be inserted, which allowed force to be applied along the longitudinal axis of the nail. Additionally, another longitudinal osteotomy had to be performed immediately distal to the pseudoarthrosis, and a bone distractor was applied in between. Thus, the nail loosened and could be removed completely. The bony defect was filled with autologous bone graft and a 9-hole AO tibial plate was applied to stabilize the tibia. We report on the breakage of this system and the surgical management of this complication.

The purpose of this study was radiologic assessment of osteoarthritis after arthroscopic partial meniscectomy. At an average followup of 53.5 months, 284 consecutive patients were retrospectively evaluated clinically and radiologically. Two hundred forty-seven patients had been treated for medial (Group I) and 37 for lateral meniscal tears (Group II). Preoperative radiographs were compared with those at followup and were classified. The results were analyzed statistically. Osteoarthritic changes were classified as being worse in 38% of the patients after medial and in 24% of the patients after lateral arthroscopic partial meniscectomy. Further subclassification and comparison of patients with or without already existing articular surface damage at the time of arthroscopy were not found to have significant impact on the prevention of osteoarthritic changes. Patients who were older than 40 years of age and who had undergone arthroscopic partial medial meniscectomy were radiologically classified with a significantly higher rate of osteoarthritis than patients who were younger than 40 years. Partial medial or lateral meniscectomy leads to a significant increase of osteoarthritic changes, even when this intervention is performed arthroscopically.

From 1977 through 1992 a total of 25 children (age 4 months to 14 years) were hospitalized for pelvic fractures. Clinical outcome and X-ray evaluation had been recorded and were retrieved for 21 children. In 3 patients pelvic fractures required surgery. All pelvic fractures healed uneventfully whether treated by surgery or conservatively. Concomitant injuries, treatment, and types of pelvic fracture are discussed.

The KT-1000 arthrometer was used to measure anterior tibial displacement in patients with acute unilateral anterior cruciate ligament (ACL) disruptions. Measurement revealed 11.5 mm absolute displacement on the injured side and 3.6 mm side-to-side difference with the 89 N test, 15.2 mm absolute displacement and 6.1 mm side-to-side difference with the manual maximum displacement test, and 8.5 mm displacement and 2.0 mm side-to-side difference with the active quadriceps test. Chronic anterior instabilities measured 13.0 mm absolute displacement on the involved side and 5.4 mm side-to-side difference with the 89N test, 17.7 mm displacement and 8.6 mm side-to-side difference with the manual maximum displacement test, 10.8 mm displacement and 4.4 mm side-to-side difference with the active quadriceps test. Testing technique, measurements in control subjects without previous knee injuries, and displacement measurements of other authors and other instrumented testing devices are described.

Two hundred consecutive patients were treated for medial meniscus lesions by partial arthroscopic medial meniscectomy. Only patients with intact cruciate and collateral ligaments prior to surgery and at arthroscopy were accepted for the study. Although all patients denied a new trauma, 12 patients (6%) were found to have increased anterior instability and 43 patients (22%) to have increased medial instability at follow-up 53.5 months after surgery. KT-1000 measurements in knees with increased anterior tibial translation revealed an average side-to-side difference of 4.7 mm.

Changes in axial tibial rotation after anterior cruciate ligament sectioning were evaluated in 14 fresh human knee joints. Simulation of vertical stance in a quadriceps-stabilized knee was performed. Internal and external rotational torques were applied before and after anterior cruciate ligament sectioning. Pivot shift tests were done in the intact and anterior cruciate ligament sectioned knee. Results of pivot shift tests were all negative before sectioning and positive after isolated sectioning. No significant change in axial rotation occurred between the intact and sectioned knee for external rotation (P = 0.24) or internal rotation (P = 0.12). Presence of a load at the femoral housing in both the intact and ligament-sectioned knees caused a significant change in external rotation (P < 0.0001). No significant change was noted in internal rotation between loaded and unloaded states (P = 0.70). Total tibial rotation in the intact knee was noted to vary between 31 degrees at 0 degree of flexion and 42 degrees at 60 degrees of flexion. These results suggest that the anterior cruciate ligament does not play a significant role in limiting axial rotation and that rotational instability is not a major factor after isolated anterior cruciate ligament rupture.

The purpose of this study was to determine the influence of preexisting chondromalacia at time of surgery on the results at a minimum of 5 years follow-up of arthroscopic partial meniscectomy. The patients were divided into two groups: group I (87 patients, average age 29.8 years) with no intraoperative findings of chondromalacia at the time of surgery, and group II (234 patients, average age 39.2 years) with chondromalacia at the time of surgery. The follow-up period was 70-86 months, with the criterion of a minimum of 5 years in each patient. Postoperative changes were evaluated according to Fairbank's classification and preoperative X-rays were compared to follow-up X-rays. For statistical analysis the Mann-Whitney test was used. In both groups arthroscopic partial lateral meniscectomy led to worse results in respect of the development of osteoarthritis. Following partial medial meniscectomy preexisting chondromalacia had a negative influence on the radiological outcome. An increase of osteoarthritis was also proven in our patient population which was statistically significantly related to age and female sex (P = 0.002).

The KT-1000 was used to measure anterior tibial displacement in three populations: normal subjects (n = 120), patients with unilateral acute anterior cruciate ligament (ACL) disruptions (n = 105), and patients with chronic unilateral ACL disruptions who were scheduled for ACL reconstructions (n = 159). All patients with ACL disruptions were measured with and without anesthesia. Tibial displacement under three loading conditions was measured: 89-N anterior displacement force, manual maximum displacement force, and quadriceps contraction to lift the leg. The measurements of the normal knee in the injured populations were not significantly different from those of the knees in the normal population on any test. The injured knee tested with and without anesthesia was significantly different from the normal knee on all tests. The right-left difference in the normal population as less than 3 mm in 98% of patients in the 89-N test, 97% in the manual maximum test, and 99% in the quadriceps active test. The largest amount of displacement and the greatest difference in displacement between the injured and the normal knee was produced by the manual maximum test. The manual maximum injured-minus-normal knee displacement was 3 mm or more in 99% of patients with chronic ACL disruptions and in 95% of patients with acute ACL disruptions.

Follow-up evaluations were carried out in 84 patients examined 5-8 years after sustaining an acute traumatic hemarthrosis of the knee. The initial examination performed within 2 weeks of injury had revealed 18 patients with a stable knee and 66 with anterior instability. Twelve of the patients underwent anterior cruciate ligament reconstruction within 3 months of injury and 11 more did so between 1 and 3 years after injury. To document joint deterioration at follow-up, bone scintigraphy and conventional anteroposterior, lateral, and tunnel X-rays were taken. Medial, lateral, patellofemoral and patellar uptake in bone scintigraphy was graded from 0 to 4. Six radiological variables were graded at eight different sites. Sixty-three patients (75%) had a positive bone scan and 69 patients (82%) showed radiological changes. Bone scan and X-ray scores were both significantly higher in the reconstructed knees.