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In the course of a prospective investigation 17 patients with operatively treated acute anterior cruciate ligament ruptures received an isokinetic muscle training with high motion velocities in addition to the common physiotherapy from the 7th to the 19th week after operation. The comparative group consisted of 17 patients with operatively treated acute anterior cruciate ligament ruptures who were receiving the common physiotherapy only. The aim of the study was to improve both the postoperative dysbalance between agonists and antagonists and the active muscular stabilisation of the knee. The isokinetic muscle training was done with 150 degrees/s and a motion limit for flexion/extension of 0-20-90 degrees. The postoperative muscular dysbalance was improved significantly in the isokinetic group after 6 weeks of training compared to the control group. The flexion/extension ratio of the operated leg at 60 degrees/s came to 100% in the training group compared to 135% in the control group. This difference was even more apparent at 180 degrees/s with 100% in the isokinetic group compared to 160% in the control group and at 240 degrees/s with 110% compared to 200% respectively. The average maximum torque was 10 to 15% better with the training group as with the control group though there was no training of maximum force done explicitly. There was no effect on the postoperative anterior stability of the knee.

UNLABELLED In a prospective study we investigated the value regarding muscle strength of two stairclimbers with either coupled or non-coupled pedals at either high or low stepping frequency. Following autologous patellar tendon graft surgery 14 patients for each group completed a strict exercising program. After 6 weeks of training a clear advantage was found for the group stepping at low speed with coupled pedals when measuring: At 60 degree/s the average maximum torque of extension increased from 37.7 to 61.7% as compared to a control group (30 to 47.2%). Analogous the percent ratio of flexion/extension (H/Q ratio) improved significantly. During the second training period the improvement of the extension strength as well as the H/Q ratio was found to be only marginal. No negative effects of this type of training on ligament stability could be detected. CONCLUSIONS Regarding a faster recovery of muscle strength and the improvement of the intermuscular coordination, the stairclimber training, beginning with week 7 after surgery and lasting over a period of 6 weeks, is considered advantageous, especially when exercising is done at low speed and with coupled pedals.

Die Ruptur des vorderen Kreuzbands (VKB) gehort zu den haufigsten Gelenkverletzungen. Die operative Versorgung ist heute als Mittel der Wahl anerkannt, doch ist bislang nur wenig uber die postoperative Zunahme des Knorpelschadens und dessen Verteilung nach Rekonstruktion des VKB bekannt. In einer prospektiven Studie wurden 150 VKB-Rupturen akut (Median 7 Tage) mit augmentierter Reinsertion (n=41) bzw. Patellarsehnenersatzplastik (BTB, n=24) oder chronisch (Median 369 Tage) mit BTB (n=85) versorgt. Eine “Second-look”-Arthroskopie im Rahmen der Metallentfernung sowie eine klinische Nachuntersuchung ein Jahr nach dem chirurgischen Eingriff erfassten den klinischen Befund sowie Veranderungen des Knorpelstatus. Wir fanden eine Zunahme und Ausdehnung der Knorpelschaden bei 86 (57%) der 150 untersuchten Patienten. Die Unterschiede zwischen den Operationsgruppen waren jedoch nicht signifikant und unabhangig vom Zeitpunkt der Operation. Nach BTB zeigten sich signifikante Zunahmen der Knorpelschaden insbesondere im medialen und retropatellaren Kompartiment, nach augmentierter Reinsertion diffus. Die klinische Untersuchung ergab keine signifikanten Unterschiede bezuglich des Lysholm-Scores sowie des funktionellen und subjektiven Ergebnisses zwischen den Operationsgruppen. Der Anteil der postoperativen Instabilitat war jedoch hoch (positiver Pivot-Shift 25%, positiver Lachmann-Test 57%), sodass wir am ehesten die postoperative Instabilitat als Ursache fur die grose Zunahme der Knorpelschaden annehmen.

During a 12-year period (1/88–12/99), 4,526 arthroscopic (ASC) of the knee joint were performed at our clinic. 279 of the patients involved were aged between 0 an 17 years (at the time of the procedure). 162 out of these 279 ASCs were performed posttraumatically after fresh injuries; 32 patients were children (age 6–12 years), 130 adolescents (age 13–17 years).

Diese Studie prasentiert die 5-Jahres-Ergebnisse (56–63 Monate postoperativ) von 76 der an unserer Klinik wegen vorderer Kreuzbandruptur (19 frische Rupturen = Gruppe A, 57 chronische vordere Instabilitaten = Gruppe B) zwischen Mai 1991 und Oktober 1993 operierten 119 Patienten (46 w., 73 m.) nach arthroskopisch gestutzter autologer Patellarsehnenersatzplastik des vorderen Kreuzbands. Die Nachuntersuchung erbrachte fur den Lysholm-Score eine durchschnittliche Punktezahl von 94,6 Punkten (Gruppe A = 97,1 Punkte, Gruppe B = 93,8 Punkte). Im IKDC-Score erreichten 21,1% der Patienten Level A (Gruppe A = 31,6%, Gruppe B = 17,5%), Level B 57,9% (Gruppe A 52,6%, Gruppe B 59.6%) sowie Level C 19,7% (Gruppe A 15,8%, Gruppe B 21,7%) und Level D in einem Fall aus Gruppe B. In 9 Fallen (11,8%, Gruppe A = 21,1%, Gruppe B = 8,8%) fand sich ein Streckdefizit bis zu 10° im Vergleich zur Gegenseite, in lediglich einem Fall aus Gruppe A (1,3%) von mehr als 10°. Eine Beugehemmung bis zu 15° zeigte sich bei 12 (15,8%, Gruppe A = 21,1%, Gruppe B = 14,0%), eine von mehr als 15° bei 3 (3,9%, Gruppe A = 5,3%, Gruppe B = 3,5%) der nachuntersuchten Patienten. Die KT-1000-Messung ergab im Vergleich zur nicht operierten Gegenseite eine durchschnittliche ventrale Translationsdifferenz von 2,5 mm bei 90 N (Gruppe A = 2.4 mm, Gruppe B = 2,5 mm), 2,8 mm bei 133 N (Gruppe A = 2,7 mm, Gruppe B 2,8 mm) sowie 3.2 mm (beide Gruppen) bei maximaler manueller Zugkraft. Der Unterschied der im Rahmen der Cybex-Messung erhobenen Maximalkraft (60°/s) und Kraftausdauer (240°/s) der Quadrizepsmuskulatur zwischen operierter und nicht operierter Seite war statistisch ebenso nicht signifikant wie der der Oberschenkelbeuger. Die konventionell radiographische Nachuntersuchung ergab in 22,3% aller Patienten (Gruppe A = 26,3%, Gruppe B = 21,1%) erst- oder zweitgradige Arthrosezeichen in mindestens einem Kompartiment. Zusammenfassend zeigten die Patienten nach autologer Patellarsehnenersatzplastik des vorderen Kreuzbands wegen frischer ACL-Ruptur im IKDC-Score die besseren Langzeitergebnisse als solche mit einer BTB-Plastik wegen chronischer vorderer Instabilitat. Im Lysholm-Score und der KT-1000-Messung der objektiven Instabilitat ergaben sich lediglich geringwertig, nicht signifikant bessere Ergebnisse fur die Patellarsehnenersatzplastiken nach frischer ACL-Ruptur, in der Cybex-Messung der isokinetischen Muskelkraft dagegen keine Unterschiede.

Die distale Femurmarknagelung ist in den letzten Jahren ein zunehmend gangiges Verfahren geworden. Die Hauptindikationsgebiete der retrograden Femurmarknagelung sind die distalen Femurfrakturen einschlieslich der dia- und perkondylaren Gelenkfrakturen des distalen Femur, Korrekturosteotomien und periprothetische distale Femurfrakturen nach Kniegelenkimplantation. In der Diskussion ist die Implantatentfernung, welche zu einem erneuten Schaden im Bereich des Kniegelenkes fuhrt. Um den operativen Schaden der Implantatentfernung zu minimieren, wurde eine arthroskopisch gestutzte Vorgehensweise gewahlt. Die arthroskopisch unterstutzte Metallentfernung war bei allen Patienten moglich. Intraoperativ konnten arthroskopisch bei 2/3 der Falle unauffallige Gelenkverhaltnisse gefunden werden. Die arthroskopisch gestutzte Entfernung retrograder Marknagel ist eine schonende Vorgehensweise, welche die minimal-invasive Entfernung retrograder Marknagel ermoglicht und dabei mit Hilfe der arthroskopischen Sicht sekundare Schaden im Bereich des Knies durch schwieriges Aufsuchen des Nageleintritts verhindert. Dieses Verfahren ist so schonend bei der Entfernung retrograder Marknagel des distalen Femur, dass wir die Metallentfernung – mit Ausnahme von periprothetischen Frakturen – bei jungeren Patienten (

Between January 1986 and August 1995, we treated 86 patients suffering from lateral displacement of the patella with arthroscopic medial tightening and lateral release after a conservative functional treatment remained unsuccessful. 49 patients were available for follow-up studies. 29 patients were treated after primary dislocation of the patella, and 20 patients after recurrent dislocations (2–20). The lateral release was performed by arthroscopy in 28 patients and in 21 patients in an open procedure. The mean follow-up time was 47.3 months. The rate of reluxation was 8 %. In the opinion of the patients, 44 (90 % of the follow-up) operations were evaluated as good/very good, the average Lysholm score was 87.3 ± 13.9. The clinical results were influenced by the point of time of the operation. Patients with monoluxation showed a lower rate of reluxation (3 % vs. 15 %) and superior functional and subjective results than those with recurrent dislocation. However, there were no significant differences between the open and closed performed lateral release. We recommend the technique presented here as a minimal-invasive method especially for patients with monoluxation of the patella.

Ultrasound is not so far a standard procedure to visualize the anterior drawer following anterior cruciate ligament (ACL) lesions. This is because the described techniques are either technically difficult or depend on the experience of the performer and are not standardized. The purpose of this prospective analysis on ACL intact, ACL deficient and ACL reconstructed knees was to compare the diagnostic accuracy of prone ultrasonographic Lachman testing with KT-1000 measurements in the same study population. Our technique is based on a prone position of the patient. The thigh lies on the table surface such that the patella has no contact. The lower leg is placed on a roll in the ankle area and flexed to 30 degrees . The transducer (5 MHz) is positioned over the medial aspect of the popliteal fossa to visualize the femoral condyle as well as the tibial head. Under ultrasound control the lower leg is manually lifted as far the thigh stays in contact with the surface defining the start position. The lower leg is then released and drawn by gravity into the anterior drawer position, the final position. The distance between the posterior tangent from the medial femoral condyle to the medial tibial plateau was registered by three independent ultrasound measurements of the injured knee. The uninvolved opposite knee served as an internal control. The same procedure was done using a KT-1000 device (89 and 133 Newton and manual maximum force). The patients were split into two groups: acute injury (A), and (B) 6 months following ACL repair with a patellar tendon graft. All patients then underwent arthroscopy. In group A with acute ACL lesions the anterior drawer resulted in 14.1 mm (+/- 3.5) and was significantly (P < 0.001) different from the contralateral knee (7.7 mm +/- 2.9). The KT 1000 showed a comparable difference with 14.4 mm (+/- 3.9) for the injured knee and 8.3 mm (+/- 3.4) for the uninjured (P < 0.001). Sonometrically, group B patients showed no clear difference between the repaired (9.9 mm +/- 2.7) knee and its control (8.1 mm +/- 2.5). This was found for the KT-1000 results as well. The results derived from the ultrasound evaluation of the anterior drawer correlated well with those from the KT-1000 (r = 0.46). Based on a minimum intra-individual difference of 5 mm in the ultrasound measured anterior drawer, the sensitivity of the test in group A resulted in 0.96, and the specificity in 0.98. The described technique is reproducible, painless and easy to perform in order to evaluate acute ACL tears using any commercially available ultrasound device. The reproducibility is similar to the KT-1000 device. We recommend this technique for use in cases of acute ACL tears as well as in the follow-up of ACL repair.

The results of prospective anterior cruciate ligament (ACL) refixation in 33 patients with high proximal rupture is reported at 20-28 months' follow-up: mean age was 31.1 +/- 12.5 years. The surgical technique was a specially developed refixation of the ACL using a multiple suture loop (modified Marshall technique) augmented with intra-articular PDS II (polydioxanon, resorbable, Ethicon, Hamburg, Germany) to avoid derangement of blood circulation and to guarantee early functional rehabilitation. All patients were operated on within 7.3 +/- 4.5 days after injury. According to the IKDC evaluation score, 22 patients showed excellent and 10 patients good subjective function. Twenty regained their pre-injury level of activity. Anterior stability was tested manually and by KT-1000 max (Medmetric, San Diego). Twenty-eight patients had a firm end-point, although there was a positive Lachman test in 16 patients. Maximal joint laxity as measured by KT-1000 showed a 1-2 mm, 3-5 mm, 6-10 mm and10 mm anterior drawer for 16, 14, 2 and 1 patients, respectively. Twenty-five of the evaluated knee joints had a negative pivot shift test. Three patients had a limited range of motion. The potential advantages of PDS II-augmented refixation of acute proximal ACL ruptures are anatomic reconstruction without destruction of other anatomic structures used as grafts, early functional rehabilitation and possibly better proprioception.

Grundsatzlich sind 4 posttraumatische Zustande des proximalen Femur durch Osteotomien beeinflusbar: Rezidivierende Huftluxationen und -subluxationen, Femurkopfnekrosen, Pseudarthrosen, Deformitaten. Unter Berucksichtigung der individuellen Situation ist dabei in allen Fallen ein diagnostisches, indikatorisches und therapeutisches Raster zu respektieren, das sich im wesentlichen aus folgenden Schritten aufbaut: 1. Analyse des Problems unter Berucksichtigung von Vorgeschichte, Klinik und bildgebender Diagnostik; 2. Indikation zur Osteotomie; 3. zeichnerische Planung; 4. Operationstechnik. Spezifische diagnostische, indikatorische und operationstechnische Besonderheiten dieser posttraumatischen Veranderungen werden beschrieben. Auf Korrekturen von Deformitaten in der Frontal- und Sagittalebene, von Translationen, von Langen- und Torsionsdifferenzen wird speziell eingegangen. Der klinischen, ubersichtsradiographischen und computertomographischen/sonographischen Analyse der Beingeometrie kommt hierbei ein zentraler Stellenwert zu. Bei der Vielfalt und Komplexitat posttraumatischer Zustande des proximalen Femur kann nur eine perfekte masgeschneiderte Losung die Antwort auf ein ganz individuelles Problem sein.

We examined 38 patients with an arthroscopic bioabsorbable tack repair for anterior shoulder instability in a prospective evaluation. The mean follow-up was 22 months (range 12 to 33). The average age was 28.4 years (range 15 to 57), the operation was performed at average of 50 months (3 to 244 months) after injury. Assessment using the Rowe score revealed excellent results in 33 and good results in 3 patients. 1 patient had a fair result and 1 had a poor result. 26 shoulders obtained full range of motion, 11 had minor (< 10 °) loss of external rotation, 1 experienced greater (< 20 °) loss of external rotation. 3 of the 38 patients (8 %) had recurrent instability, 1 patient with 2 preceding operations and atraumatic and voluntary dislocation, respectively. The recurrence rate of arthroscopic Bankart repair with bioabsorbable tacks are comparable to open Bankart procedures. Success of the procedure depends on appropriate surgical technique and suitable selection of patients with unidirectional, posttraumatic, anterior instability who are found to have well-developed ligamentous tissue.

In a series of 1850 consecutive knee arthroscopies between 1991 and 1995, plicasyndrome was diagnosed and resected by arthroscopy in 102 patients (5.5%). Clinical response was evaluated for 38 of 54 patients with an isolated plicasyndrome by use of a modified Lysholm questionnaire at an average follow-up of 31 months (range, 8-78 months). Excellent or good results were obtained in 90% of 21 patients without plica-induced lesions of the cartilage (group 1) and poor results in 10%. Only 64% of 17 patients with plica-induced lesions of the cartilage (group 2) had excellent or good results. Both groups showed an improvement for range of motion and swelling post-operatively. The mean time for rehabilitation was 3.2 and 1.7 months for patients with and without cartilage lesions, respectively.

120 Patienten nach Ersatz des vorderen Kreuzbandes (VKB) mit La-Fil-Kohlefaserprothese wurden retrospektiv mittels Fragebogen und 80 Patienten klinisch nach im Mittel 10 ± 2 Jahren untersucht. Die subjektive Beurteilung ergab 60 % zufriedene Patienten bei deutlich vermindertem Aktivitatsniveau. Als objektive Komplikationen waren bei 72,5 % der Patienten die C-Faser rupturiert und bei 68 % der Patienten synoviale Reaktionen zu beobachten. Rontgenologisch zeigten sich in bis zu 59 % der Falle arthrotische Veranderungen. Die mit C-Faser rekonstruierten Collateralbander (85 % medial, 5,8 % lateral) waren zu 75 % stabil. Fur das Versagen der Kohlefaserprothesen scheinen weniger die Aktivitat oder die Zeit als vielmehr das Einwachsverhalten der Prothesen eine Rolle zu spielen. Im Langzeitverlauf fuhrt die reaktive Synovitis uber katabole Enzymreaktionen zur Gelenkdestruktion. Klinische Zeichen sind rezidivierende Gelenkergusse und Schmerzen. Zur Unterbrechung des Circulus vitiosus ist die (arthroskopische) Synovektomie indiziert.

Intraindividual length differences up to 1.2 cm in femora, up to 1.0 cm in tibiae and up to 1.4 cm in whole leg length can be regarded as physiological. Length differences in childhood are frequently compensated for by functional adaptation in the chain of adjacent limbs. In adults, however, that adaptability is diminished and correction osteotomy after post-traumatic shortening may therefore be indicated more generously dependent on local and general criteria of operability. A conscientious analysis of bone geometry by clinical means, radiology and computed tomography is mandatory for the indication and planning of any correction osteotomy. Intraindividual leg length differences of more than 4 cm are preferentially treated by continuous callus distraction techniques. Shortening by less than 4 cm, however, is suitable for a one-stage stepwise prolongation osteotomy in the metaphysis of the femur, i.e. in the subtrochanteric or supracondylar region. These osteotomies are than stabilized by long condylar plates; the bony defects are filled up by auto- or allogenous corticospongeous bone. Simple modifications of the stepwise prolongation osteotomy permit additional corrections of torsional deviations up to 20 degrees or of axial deviations in the frontal or sagittal plane up to 5 degrees. The results of 24 one-stage stepwise prolongation osteotomies of the subtrochanteric and supracondylar femur after congenital or post-traumatic shortening are presented as well as the reason and respective therapies for three important complications.

We examined 30 patients with an arthroscopic suture repair for anterior shoulder instability in a retrospective evaluation. The follow-up period ranged from 12 to 58 months with an average of 22 months. Arthroscopic suture repairs were done on 14 patients (acute group, average age 26.1 years) with acute detached glenoid labrum, confirmed on arthro-CT, within 10 days after the injury and on 16 patients (secondary group, average age 25 years) with chronic should dislocation. The evaluation according to the Rowe scale resulted in a mean score of 97.1 for the acute group compared with 92.7 for the secondary group. In each group we found one recurrent dislocation, which in the acute group was due to an adequate trauma. Two of the 14 acute group patients showed a reduction in external rotation of up to 20 degrees, compared with 6 patients in the secondary group. The external rotation of one patient in the secondary group was reduced to 40 degrees. The isokinetic muscle strength was decreased in both groups, both for 60 degrees/s and for 120 degrees/s, to 85% compared with the healthy side. The primary surgical therapy of young patients (below 25 years) with an acute shoulder dislocation and a detached glenoid labrum is recommended owing to the lower redislocation rate, an overall shortened course of treatment and a trend to better postsurgical range of motion.

We reviewed 53 of 58 patients who had primary repairs of posterior cruciate ligament injuries between 1981 and 1988. Sixteen patients had isolated posterior cru ciate ligament ruptures, 16 had complex injuries with capsular and collateral ligament involvement, and 21 had additional anterior cruciate ligament ruptures. For ty-six patients were treated by transosseous multiple- loop sutures and seven with bony avulsions by screw osteosynthesis. The mean follow-up time was 7.5 years (range, 3 to 12). All patients were examined subjectively (questionnaire) and objectively (clinical ex amination, KT-1000 arthrometer, functional testing, ra diographs, and Cybex II isokinetic strength analysis). The results were graded according to the International Knee Documentation Committee evaluation form and the Lysholm score. The average Lysholm score was 82.4 (range, 40 to 100). Thirty-eight patients returned to their preinjury activities at the same intensity level. The patients' subjective assessments were normal or nearly normal in 35 patients. The posterior drawer test was negative or 1 + in 46 patients. Cybex isokinetic strength analysis revealed a decrease in quadriceps muscle strength of the involved limb by 10.5% (P < 0.01). Our data suggest that primary repair of posterior cruciate ligament ruptures provides good results after 8 years in approximately two thirds of the patients. Distal ligamentous ruptures, lack of athletic activity, and tem porary olecranization correlated with poor results. Bony avulsions, midsubstance or proximal ruptures, and athletic activity correlated with good results.

Die vorliegende Arbeit charakterisiert die mechanisch bedingten Berufserkrankungen der Sehnenscheiden, des Sehnengleitgewebes und der Sehnen- oder Muskelansatze sowie der Schleimbeutel. Es werden das klinische Erscheinungsbild, die verursachende Schadigung und die Richtlinien der Begutachtung besprochen.

Ziel der retrospektiven Studie war die Evaluation der Arthroskopie in der Therapie der Arthrose des oberen Sprunggelenks (OSG). Im 10-Jahres-Zeitraum 1988–1997 wurden insgesamt 358 Arthroskopien des OSG durchgefuhrt — in 178 Fallen indiziert durch eine Arthrose. Von 132 erreichbaren Patienten beantworteten 124 einen Fragebogen. Davon wurden 90 (73%) Patienten 94 (37–152) Monate nach der Arthroskopie nachuntersucht und entsprechend dem Score nach Evanski und Waugh bewertet. Alle Arthroskopien erfolgten unter Flussigkeitsfullung uber einen anterolateralen und anteromedialen Zugang. Lediglich in 5 Fallen wurde das posteriore Kompartment zusatzlich gespiegelt. Generell wurde sowohl auf Blutsperren als auch auf mechanische Gelenkdistraktion verzichtet. Von insgesamt 12 (6,7%) Komplikationen waren lediglich 3 Hamatome (1,7%) revisionsbedurftig, eines davon mit arteriovenoser (AV-)Fistel. 5 Sensibilitatsstorungen waren passager, Infektionen traten nicht auf. Von den 124 Patienten der Fragebogengruppe bewerteten 11% das Ergebnis nach der Arthroskopie als sehr gut, 46% als gut, 22% als befriedigend und 21% als schlecht. 22% der Patienten wurden in der Folgezeit erneut am OSG operiert, davon waren 9% arthroskopische Revisionen, 3% Arthrodesen und 10% Denervierungen. Der gesamte Bewegungsumfang vergroserte sich um 15% von praoperativ 10/0/40° Extension/Flexion auf 15/0/44° zum Zeitpunkt der Nachuntersuchung. Der Evanski-Score verbesserte sich statistisch hoch signifikant (p

In a prospective study we investigated the value regarding muscle strength of two stairclimbers with either coupled or non-coupled pedals at either high or low stepping frequency. Following autologous patellar tendon graft surgery 14 patients for each group completed a strict exercising program. After 6 weeks of training a clear advantage was found for the group stepping at low speed with coupled pedals when measuring: At 60 degree/s the average maximum torque of extension increased from 37.7 to 61.7% as compared to a control group (30 to 47.2%). Analogous the percent ratio of flexion/extension (H/Q ratio) improved significantly. During the second training period the improvement of the extension strength as well as the H/Q ratio was found to be only marginal. No negative effects of this type of training on ligament stability could be detected.Regarding a faster recovery of muscle strength and the improvement of the intermuscular coordination, the stairclimber training, beginning with week 7 after surgery and lasting over a period of 6 weeks, is considered advantageous, especially when exercising is done at low speed and with coupled pedals.

The anterior cruciate ligament (ACL) rupture is among the most frequent injuries of the joints. Actually, there is no doubt regarding the necessity for surgical treatment. However, little is known about the progression of osteochondral damages and their distribution following reconstruction of the ACL. We treated 150 tears of the ACL either acute (median 7d) with augmented reinsertion (n = 41) and with autologous bone patella tendon graft (n = 24) or chronic (median 369d) with autologous bone patella tendon graft (n = 85). The study design was prospective. All osteochondral defects were documented in the six compartments. Second look arthroscopy and clinical examination were performed after twelve months in the course of removal of implants and possible changes of the osteochondral state were evaluated. Detoriation of osteochondral state was seen in 86 (57%) of 150 patients, while there was no statistical difference between the three groups. The time of operation had no influence on the osteochondral damage. There was a significant increase of chondral damages in the medial and retropatellar compartment after autologous bone patella tendon graft, while the changes after augmented reinsertion were diffuse. There were no significant differences in the clinical examination between the three groups regarding the Lysholm score and the functional and subjective outcome. However, postoperative instability was frequently observed (positive pivot-shift 25%, positive Lachmann test 57%). We suggest that postoperative instability should have led to the increased osteochondral damages.

This study presents the five-year follow-up-results (range 56 to 63 months) of 76 of 119 patients who had had arthroscopically assisted reconstruction of the anterior cruciate ligament with use of the central third patellar tendon for acute rupture (19 patients = group A) or chronic ACL insufficiency (57 patients = group B) between may 1991 and october 1993 in the Department of Trauma Surgery University Hospital Ulm. The average Lysholm knee score was 94.6 points (group A = 97.1, group B = 93.8 points). The IKDC-score rated 21.1% of all patients as A (group A = 31.6%, group B = 17.5%), 57.9% as B (group A = 52.6%, group B = 59.6%), 19.7% as C (group A = 15.8%, group B 21.7%) and one patient of group B as level D. 9 patients (= 11.8%, group A = 21.1%, group B = 8.8%) showed up to 10 degree extension loss (compared with contralateral knee), one patient of group A (1.3%) more than 10 degree. A flexion loss up to 15 degree was seen in 12 patients (= 15.8%, group A = 21.1%, group B = 14.0%), of more than 15 degree in 3 patients (= 3.9%, group A = 5.3%, group B = 3.5%). The average KT-1000-side-to-side difference was 2.5 mm with 90 N (group A 2.4 mm, group B = 2.5 mm), 2.8 mm with 133 N (group A = 2.7 mm, group B = 2.8 mm) and 3.2 mm (both groups) for manual maximum. There was no statistically significant difference in quadriceps and hamstring isokinetic strength (Cybex) of operated vs. unaffected limb for 60/s as well as 240/s. X-ray analysis showed arthrotic signs of minimum one compartment in 22.3% of all patients (group A = 26.3%, group B = 21.1%). In summary, we found better long-term results of IKDC-score in patients with autogenous patellar tendon graft for acute ACL-rupture vs. chronic ACL insufficiency. In Lysholm knee score and KT-1000 arthrometric measurement we just saw little but not statistically significant differences between the two groups. The isokinetic strength of quadriceps and hamstring were similar between operated vs. unaffected limb as well as between group A and B.

Objective. To identify an augmentation technique which would provide mechanical protection for the healing posterior cruciate ligament. Design. Six human knee specimens were tested in vitro for posterior knee joint stability after augmenting the cut posterior cruciate ligament by six different techniques using a resorbable double strand Polydioxanone augmentation device. Background. A fresh isolated rupture of the posterior cruciate ligament is often treated conservatively. Results have shown that it can heal, but ligament elongations occur frequently. Therefore a method is needed to provide posterior knee joint stability during ligament healing. Methods. The effect of different femoral augmentation insertions on posterior knee stability was tested by recording the antero-posterior (AP) position of the tibia and the augmentation force. Testing was performed during flexion–extension cycles and under posterior shear loads. Results. The insertion combination that proved to stabilize the joints best consisted of one augmentation strand leading along the antero-lateral posterior cruciate ligament fibres and inserting at the distal end of the Blumensaat line and one strand leading along the posteriormedial fibres and inserting in the middle of the Blumensaat line. AP translations similar to those occurring in healthy knee joints could be achieved. Conclusions. It is possible to restore normal posterior knee joint stability by implanting a double strand augmentation device. This can help a posterior cruciate ligament to heal under non-elongated conditions. Relevance The posterior cruciate ligament augmentation procedure developed in this study represents a clinical alternative to conservative treatment of fresh isolated posterior cruciate ligament tears. It can prevent post-traumatic instability and thus a developing arthrosis.

Recently, the retrograde femoral nailing has become a procedure with increasing acceptance. Indications for the retrograde femur nail are distal femoral fractures including dia- and transcondylar fractures, supracondylar osteotomies and distal periprosthetic femur fractures after total knee joint replacement. Controversial discussion is carried on about the implant removal, which is potentially afflicted with further damage to the knee joint. To minimize the operative damage due to the implant removal, an arthroscopic assisted procedure has been selected. The arthroscopic assisted implant removal was possible in all of our patients. Intraoperatively, 2/3 of the patients showed normal age-related findings of the chondral and meniscal structures. The arthroscopic assisted implant removal is a gentle procedure, which allows minimal invasive extraction of retrograde femur nails and prevents secondary damage to the knee joint due to the otherwise difficult localisation of the implant. The advantages of this procedure concerning gentleness and diagnostic capabilities are as convincing, that we indicate implant removal of retrograde femur nails in all younger patients (60 years), except in periprosthetic fractures.

Between January 1986 and August 1995, we treated 86 patients suffering from lateral displacement of the patella with arthroscopic medial tightening and lateral release after a conservative functional treatment remained unsuccessful. 49 patients were available for follow-up studies. 29 patients were treated after primary dislocation of the patella, and 20 patients after recurrent dislocations (2-20). The lateral release was performed by arthroscopy in 28 patients and in 21 patients in an open procedure. The mean follow-up time was 47.3 months. The rate of reluxation was 8%. In the opinion of the patients, 44 (90% of the follow-up) operations were evaluated as good/very good, the average Lysholm score was 87.3 +/- 13.9. The clinical results were influenced by the point of time of the operation. Patients with monoluxation showed a lower rate of reluxation (3% vs. 15%) and superior functional and subjective results than those with recurrent dislocation. However, there were no significant differences between the open and closed performed lateral release. We recommend the technique presented here as a minimal-invasive method especially for patients with monoluxation of the patella.

Basically, four post-traumatic conditions of the proximal femur can be improved by corrective osteotomies: recurring luxations and subluxations of the hip joint; necrosis of the femoral head; non-unions; deformities. Dependent on the individual situation, the following procedure can be recommended, including diagnosis of deformities and indication and therapy of corrective osteotomies: analysis of the problem from the viewpoint of history, clinical findings and imaging techniques; indication for corrective osteotomy; graphic planning; operation technique. Particularities of post-traumatic conditions with regard to diagnosis, indication and surgical technique are indicated. Only with perfectly tailored concepts can we respond to the individual situation of an individual patient and reflect the variety and complexity of post-traumatic conditions of the proximal femur.

Basics of ligament augmentation are reviewed from the literature. As biomechanical in-vitro studies, animal experiments, and clinical studies show different designs and data, the results may be interpreted variably. Theoretically there is a positive effect of augmentation, but no significant improvement of clinical results is evident. The goal of our own prospective study was to check the healing capacity of a repaired and augmented ACL with respect to stability compared to a primary or secondary BTB ligament replacement with and without augmentation. 200 patients were allocated to 4 groups. In group I (G1) acute proximal ruptures were repaired arthroscopically and augmented with PDS II-cord. Patients in G2 received an acute and in G3 a late BTB ligament replacement. Additionally in G4 a late ligament replacement was augmented with a PDS II-cord. The clinical results reveal a comparative stability between G1 and G2, and gradually less stability in G3 and G4. Subjectively, knee function was felt best in G1 and G2 while being worst in G3 and G4. There is no significant difference in the mobility of knees between primary and secondary ligament replacement. An additional augmentation doesn't improve the knee stability.There is no positive effect of an augmentation technique of a biologic ligament replacement concerning stability, morbidity, complication rate, and costs. Very marginal freshly ruptured cruciate ligaments may be reinserted successfully by a biodegradable augmentation. Subjective feeling and functional stability may be at least equal to a primary ligament replacement. There are no advantages in knee mobility, when a secondary ligament replacement is performed.

We examined 38 patients with an arthroscopic bioabsorbable tack repair for anterior shoulder instability in a prospective evaluation. The mean follow-up was 22 months (range 12 to 33). The average age was 28.4 years (range 15 to 57), the operation was performed at average of 50 months (3 to 244 months) after injury. Assessment using the Rowe score revealed excellent results in 33 and good results in 3 patients. 1 patient had a fair result and 1 had a poor result. 26 should obtained full range of motion, 11 had minor (10 degrees) loss of external rotation, 1 experienced greater (20 degrees) loss of external rotation. 3 of the 38 patients (8%) had recurrent instability, 1 patient with 2 preceding operations and atraumatic and voluntary dislocation, respectively. The recurrence rate of arthroscopic Bankart repair with bioabsorbable tacks are comparable to open Bankart procedures. Success of the procedure depends on appropriate surgical technique and suitable selection of patients with unidirectional, posttraumatic, anterior instability who are found to have well-developed ligamentous tissue.

The retrospective results of carbon prostheses for knee ligament reconstruction in 120 patients, as established by questionnaire, are reported at 10 +/- 2 years follow-up. Eighty patients could also be reviewed clinically. Some 60% of the patients showed good subjective function at reduced activity level. Complications were seen in 72.5% of the patients with rupture of the carbon prosthesis and in 68% of those with synovitis. X-ray showed osteoarthritis in up to 59% of the patients. Carbon prostheses for collateral ligament reconstruction (85% medial, 5.8% lateral) were successful in 75% of cases. Activity and time seem to be less responsible for failure of the carbon prostheses than the features of growing in. Destruction of the knee joint over time is due to reactive synovitis and catabolic enzyme reaction and correlates with joint effusion and pain. If these problems appear, (arthroscopic) resection of the synovia is indicated to interrupt the circulus vitiosus.

Objective. Correct placement of tunnels for anterior cruciate ligament (ACL) reconstruction is of prime importance for the clinical outcome of the patient. In this study, the possibility of using MRI to document tunnel placement and provide a more comprehensive report following ACL reconstruction was explored at no additional cost in patients scheduled for routine knee MRI. Design and patients. One year after ACL reconstruction, 45 patients underwent clinical examination (IKCD score), radiographic examination, and MRI using a 1.5-T unit. Results. Twenty patients with good tibial and femoral attachment results were found at clinical examination to have a stable knee joint with a full range of motion. In 25 patients with suboptimal placements, examination showed either a stable knee with a decreased range of motion or instability with a normal range of motion. Conclusion. Patients’ clinical outcome, and the radiographic and MRI findings, correlated closely with the quality of operative tunnel placement. A record of this finding is important for completeness of the radiological report. Furthermore the MRI findings can be used to improve the surgical quality of tunnel placement. Because tunnel placement can be shown adequately with radiography, however, MRI cannot be justified for this reason alone, so such assessment is advised only when MRI is needed to show all postoperative features.

Intraindividual length differences up to 1.2 cm in femora, up to 1.0 cm in tibiae and up to 1.4 cm in whole leg length can be regarded as physiological. Length differences in childhood are frequently compensated for by functional adaptation in the chain of adjacent limbs. In adults, however, that adaptability is diminished and correction osteotomy after post-traumatic shortening may therefore be indicated more generously dependent on local and general criteria of operability. A conscientious analysis of bone geometry by clinical means, radiology and computed tomography is mandatory for the indication and planning of any correction osteotomy. Intraindividual leg length differences of more than 4 cm are preferentially treated by continuous callus distraction techniques. Shortening by less than 4 cm, however, is suitable for a one-stage stepwise prolongation osteotomy in the metaphysis of the femur, i.e. in the subtrochanteric or supracondylar region. These osteotomies are than stabilized by long condylar plates; the bony defects are filled up by auto- or allogenous corticospongeous bone. Simple modifications of the stepwise prolongation osteotomy permit additional corrections of torsional deviations up to 20 degrees or of axial deviations in the frontal or sagittal plane up to 5 degrees. The results of 24 one-stage stepwise prolongation osteotomies of the subtrochanteric and supracondylar femur after congenital or post-traumatic shortening are presented as well as the reason and respective therapies for three important complications.

Kniegelenknahe Frakturen schliesen intra- und extraartikulare Frakturen der distalen Femur- und proximalen Tibiametaphyse ein. Gemas der AO-Klassifikation [6] betrifft dies demnach Frakturen der Gruppen 33 und 41 mit den jeweiligen Untergruppen A, B und C.

We examined 30 patients with an arthroscopic suture repair for anterior shoulder instability in a retrospective evaluation. The follow-up period ranged from 12 to 58 months with an average of 22 months. Arthroscopic suture repairs were done on 14 patients (acute group, average age 26.1 years) with acute detached glenoid labrum, confirmed on arthro-CT, within 10 days after the injury and on 16 patients (secondary group, average age 25 years) with chronic should dislocation. The evaluation according to the Rowe scale resulted in a mean score of 97.1 for the acute group compared with 92.7 for the secondary group. In each group we found one recurrent dislocation, which in the acute group was due to an adequate trauma. Two of the 14 acute group patients showed a reduction in external rotation of up to 20 degrees, compared with 6 patients in the secondary group. The external rotation of one patient in the secondary group was reduced to 40 degrees. The isokinetic muscle strength was decreased in both groups, both for 60 degrees/s and for 120 degrees/s, to 85% compared with the healthy side. The primary surgical therapy of young patients (below 25 years) with an acute shoulder dislocation and a detached glenoid labrum is recommended owing to the lower redislocation rate, an overall shortened course of treatment and a trend to better postsurgical range of motion.

In the course of a prospective investigation 17 patients with operatively treated acute anterior cruciate ligament ruptures received an isokinetic muscle training with high motion velocities in addition to the common physiotherapy from the 7th to the 19th week after operation. The comparative group consisted of 17 patients with operatively treated acute anterior cruciate ligament ruptures who were receiving the common physiotherapy only. The aim of the study was to improve both the postoperative dysbalance between agonists and antagonists and the active muscular stabilisation of the knee. The isokinetic muscle training was done with 150 degrees/s and a motion limit for flexion/extension of 0-20-90 degrees. The postoperative muscular dysbalance was improved significantly in the isokinetic group after 6 weeks of training compared to the control group. The flexion/extension ratio of the operated leg at 60 degrees/s came to 100% in the training group compared to 135% in the control group. This difference was even more apparent at 180 degrees/s with 100% in the isokinetic group compared to 160% in the control group and at 240 degrees/s with 110% compared to 200% respectively. The average maximum torque was 10 to 15% better with the training group as with the control group though there was no training of maximum force done explicitly. There was no effect on the postoperative anterior stability of the knee.

Zur Reinsertion frischer randstandiger Rupturen des vorderen Kreuzbandes (ACL) wurde eine arthroskopische Naht- und Augmentationstechnik entwickelt. Mit einer kanulierten Nahtzange wird der distale ACL-Stumpf mit 5–7 resorbierbaren Faden durchstochen. Diese werden durch zwei femorale Bohrlocher transossar nach proximal ausgeleitet und uber einer Knochenbrucke verknupft. Eine PDS-II-Augmentationskordel wird parallel zum ACL und u-formig uber zwei weitere Bohrungen durch den Tibiakopf geleitet und femoral mit Schraube und Beilagscheibe fixiert. Sie ermoglicht eine freifunktionelle Nachbehandlung ohne Brace. Mit der verbesserten neuen 2-mm-Kordel werden eine Optimierung des Augmentationsschutzes erreicht und die Nachteile nichtresorbierbarer Materialien wie Abrieb und „stress-protec- tion” vermieden.

Between 1986 and 1991, 120 femoral fractures were treated in 116 children. The treatment of choice was conservative in young patients (overhead traction in 1- to 3-year-old children. Weber traction in 3- to 8-year-old children). Operative treatment was indicated in older children: plate fixation was performed in children between 5 and 16 years of age, while external fixation was used in children aged 2-14 years. In a retrospective study 66 femoral fractures in 62 children were reviewed and limb length checked both clinically and by ultrasound measurement. For ultrasound evaluation a special device was constructed to provide standardized measuring conditions. In 27 cases we observed specific complications related to the method. In all cases fracture healing occurred, but in 7 cases it was necessary to change the method of treatment. Ultrasound measurement revealed mean limb lengthening of 5.5 mm after overhead traction (max. 11 mm) and of 7 mm (max. 25 mm) after Weber traction. The median difference in leg length after operative treatment was 5.5 mm (max. 15 mm) for plate fixation and 8.5 mm (max. 25 mm) for external fixation. Our results allow no definitive statement on the most suitable treatment for femoral fractures in children (conservative versus operative treatment), except that children under 3 years of age are best treated by overhead traction.