G. Hehl

Tunnel placement in anterior cruciate ligament reconstruction: MRI analysis as an important factor in the radiological report.

Abstract 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.

Minimal-invasive Implantatentfernung nach retrograder Marknagelung am distalen Femur

ZusammenfassungDie distale Femurmarknagelung ist in den letzten Jahren ein zunehmend gängiges Verfahren geworden. Die Hauptindikationsgebiete der retrograden Femurmarknagelung sind die distalen Femurfrakturen einschließlich der dia- und perkondylären 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 führt. Um den operativen Schaden der Implantatentfernung zu minimieren, wurde eine arthroskopisch gestützte Vorgehensweise gewählt. Die arthroskopisch unterstützte Metallentfernung war bei allen Patienten möglich. Intraoperativ konnten arthroskopisch bei 2/3 der Fälle unauffällige Gelenkverhältnisse gefunden werden.Die arthroskopisch gestützte Entfernung retrograder Marknägel ist eine schonende Vorgehensweise, welche die minimal-invasive Entfernung retrograder Marknägel ermöglicht und dabei mit Hilfe der arthroskopischen Sicht sekundäre Schäden im Bereich des Knies durch schwieriges Aufsuchen des Nageleintritts verhindert. Dieses Verfahren ist so schonend bei der Entfernung retrograder Marknägel des distalen Femur, dass wir die Metallentfernung – mit Ausnahme von periprothetischen Frakturen – bei jüngeren Patienten (<60 Jahre) für indiziert halten.SummaryRecently, 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 minimise 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.

Ultrasound evaluation of gravity induced anterior drawer following anterior cruciate ligament lesion.

Abstract 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 °. 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 startposition. 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.

Die arthroskopisch gestützte Rekonstruktion des vorderen Kreuzbands mittels autologer Patellarsehnenersatzplastik 5-Jahres-Ergebnisse

ZusammenfassungDiese Studie präsentiert 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 Instabilitäten = Gruppe B) zwischen Mai 1991 und Oktober 1993 operierten 119 Patienten (46 w., 73 m.) nach arthroskopisch gestützter autologer Patellarsehnenersatzplastik des vorderen Kreuzbands.Die Nachuntersuchung erbrachte für 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 Fällen (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 Instabilität. Im Lysholm-Score und der KT-1000-Messung der objektiven Instabilität ergaben sich lediglich geringwertig, nicht signifikant bessere Ergebnisse für die Patellarsehnenersatzplastiken nach frischer ACL-Ruptur, in der Cybex-Messung der isokinetischen Muskelkraft dagegen keine Unterschiede.AbstractThis 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.

Clinical experience with PDS II augmentation for operative treatment of acute proximal ACL ruptures--2-year follow-up.

Abstract 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 and > 10 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.

Die einzeitige treppenförmige Verlängerungsosteotomie des Femurs

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° or of axial deviations in the frontal or sagittal plane up to 5°. 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.

Arthroskopische Kapsel-Labrum-Refixation bei der vorderen Schulterluxation. Primär- oder Sekundärversorgung?

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°, compared with 6 patients in the secondary group. The external rotation of one patient in the secondary group was reduced to 40°. The isokinetic muscle strength was decreased in both groups, both for 60°/s and for 120°/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.

Plica syndrome as a cause of recurrent knee complaints

SummaryIn 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 postoperatively. The mean time for rehabilitation was 3.2. and 1.7 months for patients with and without cartilage lesions, respectively.ZusammenfassungVon 1850 zwischen 1991–1995 durchgeführten Kniegelenkarthroskopien wurde in 102 Fällen (5,5 %) die Diagnose „Plica-Syndrom“ gestellt und eine arthroskopische Resektion vorgenommen. In 54 Fällen handelte es sich um ein isoliertes Plicasyndrom; 38 von 54 Patienten konnten im Mittel nach 31 (8–78) Monaten anhand eines modifizierten Fragebogens nach Lysholm nachkontrolliert werden. Von 21 Patienten ohne plicainduzierte Knorpelläsion (Gruppe 1) zeigten 90 % subjektiv ein sehr gutes und gutes und 10 % ein unbefriedigendes Ergebnis. Schlechtere Ergebnisse fanden sich bei den 17 Patienten mit plicainduzierter Knorpelläsion (Gruppe 2) mit 64 % subjektiv sehr guten und guten Resultaten. In beiden Gruppen konnte durch die Operation eine präoperativ bestehende Bewegungsstörung oder Schwellneigung verbessert werden. Die durchschnittliche Nachbehandlungszeit dauerte bei Patienten ohne Knorpelläsion mit durchschnittlich 1,7 Monaten gegenüber 3,2 Monaten bei Vorliegen einer Knorpelläsion nur halb so lang.

Erkrankungen der Sehnenscheiden oder des Sehnengleitgewebes sowie der Sehnen- oder Muskelansätze (2101) und der Schleimbeutel (2105)

Die vorliegende Arbeit charakterisiert die mechanisch bedingten Berufserkrankungen der Sehnenscheiden, des Sehnengleitgewebes und der Sehnen- oder Muskelansätze sowie der Schleimbeutel. Es werden das klinische Erscheinungsbild, die verursachende Schädigung und die Richtlinien der Begutachtung besprochen.ZusammenfassungThis overview characterizes the mechanically caused occupational diseases of tendon sheaths, paratenon, and tendon and muscle insertions and bursitis. The clinical picture in each, the causative damage and the guidelines for expert medical assessment are discussed.

Beurteilung von Knorpelveränderungen im Rahmen der Second-look-Arthroskopie 12 Monate nach operativer Rekonstruktion einer vorderen Kreuzbandruptur

ZusammenfassungDie Ruptur des vorderen Kreuzbands (VKB) gehört zu den häufigsten Gelenkverletzungen. Die operative Versorgung ist heute als Mittel der Wahl anerkannt, doch ist bislang nur wenig über 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 Veränderungen des Knorpelstatus.Wir fanden eine Zunahme und Ausdehnung der Knorpelschäden bei 86 (57%) der 150 untersuchten Patienten. Die Unterschiede zwischen den Operationsgruppen waren jedoch nicht signifikant und unabhängig vom Zeitpunkt der Operation. Nach BTB zeigten sich signifikante Zunahmen der Knorpelschäden insbesondere im medialen und retropatellaren Kompartiment, nach augmentierter Reinsertion diffus. Die klinische Untersuchung ergab keine signifikanten Unterschiede bezüglich des Lysholm-Scores sowie des funktionellen und subjektiven Ergebnisses zwischen den Operationsgruppen. Der Anteil der postoperativen Instabilität war jedoch hoch (positiver Pivot-Shift 25%, positiver Lachmann-Test 57%), sodass wir am ehesten die postoperative Instabilität als Ursache für die große Zunahme der Knorpelschäden annehmen.AbstractThe 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.