Fulkerson's modified Elmslie-Trillat procedure for objective patellar instability and patellofemoral pain syndrome.

Twenty two knees were either operated for objective patellar instability (Group A: 14 patients) or patellofemoral pain syndrome (Group B: 8 patients) using Fulkerson's modified Elmslie-Trillat procedure. The objective of this retrospective study was to evaluate the results of this method and to detect whether or not there were differences in the outcome comparing the two groups. Twenty knee joints (Group A: 13; group B: 7) were available for clinical and radiographic examination after an overall mean follow-up of 63 months. Duration of pre- and postoperative physical therapy was significantly longer for group B, the activity level increased significantly for these patients and the Q-angle could be corrected significantly in this group comparing pre- and postoperative values. The overall outcome (Turba score) detected no statistically significant difference between the groups, only good and excellent results were obtained. No signs of osteoarthritis were found radiologically. A pathological patellar congruence angle could be corrected significantly by this method. We conclude that Fulkerson's modified Elmslie-Trillat operation is an excellent treatment method with a very low morbidity for patients with patellofemoral malalignment after failed conservative treatment.

[Arthroscopic repair of the medial retinaculum after first time dislocation of the patella]. / Arthroskopisch unterstützte mediale Retinakulumnaht nach akuter Erstluxation der Patella.

Between March 1994 and December 1997, an arthroscopic repair of the medial retinaculum after first time dislocation of the patella was performed 38 times in 34 patients. The operative technique is being described as well as the results after an average follow-up of 25 months in 31 cases. In the group with radiologically determined predisposing factors (n = 20) as many osteochondral flakes were found as in the group without these factors, but there were significantly less chondral lesions on the lateral femoral condyle and the medial patellar facet. There were no complications during hospitalization, although in 3 (10%) cases a redislocation occurred during follow-up. According to the subjective Turba Score, 84% of the patients showed a good or very good, and 16% a fair result, including cases with redislocation. The arthroscopic repair of the medial retinaculum after first time patellar dislocation is a minimal invasive method with very low peri- and postoperative morbidity. The redislocation rate can be reduced to at least 50% compared to the published data on conservative treatment.

[Isolated coracoid fracture--open reposition and osteosynthesis--report of 3 cases]. / Die isolierte Coracoid-Fraktur--offene Reposition und Osteosynthese--Bericht über drei Fälle.

UNLABELLED: Usually coracoid-fractures are "chain-injuries" in association with complex shoulder injuries. Isolated fractures of the coracoid process are uncommon. In the literature there is no consensus about the treatment. The conservative method is generally advocated. For better recognizing the particularities of coracoid-anatomy and fracture-analysis we performed dissections on cadaver shoulders and also evaluated a useful radiologic technique for diagnosis. Between 1995 and 1997 three patients with isolated displaced coracoid-fractures had open surgical repair. The postoperative course was very good in all three cases with complete recovery of shoulder function. DISCUSSION: We believe that isolated coracoid-fractures with infero-lateral dislocation and loss of function should sustain open reduction and internal fixation with functional after treatment.

Arthroscopically assisted treatment of lateral tibial plateau fractures in skiers: use of a cannulated reduction system.

A prospective study was performed on 16 patients with lateral tibial plateau fractures. All injuries were associated with alpine or cross-country skiing. Included in the study were those patients with an articular surface depression of > or = 2 mm with radiographic findings consistent with the AO/ASIF classification of tibial plateau fractures (41 B2.2/B3.1). A combined procedure was performed with arthroscopic visualization of the knee joint and utilization of a cannulated plateau elevator. All fractures were reduced with this device with subsequent autogenous bone graft and, when indicated, transverse cancellous lag screw fixation. Follow-up was 1-6.5 years for the 16 patients, with all but two reporting resumption of activity to preinjury levels.

[Epidemiology of internal knee injuries in Alpine skiing]. / Epidemiologie von Kniebinnenverletzungen beim alpinen Skisport.

The incidence of sport injuries in Switzerland is twice as high compared to traffic injuries. Soccer and alpine skiing play the most important role in sport injuries. For the last twenty winter seasons all winter sport injuries were analysed at the hospital of Davos. About 85% are injuries caused by alpine skiing resulting in a total of 24,684 for the last twenty years. There is a great decline in the incidence of lower leg fractures with a contrary development of knee injuries. The treatment-quotient (amount of knee injuries in alpine skiers per 10(4) kilometers of vertical drop skied) has increased over the last seasons. Nowadays one part of four skiing injuries is an injury of the knee ligaments. In skiing areas favored by beginners, we have observed an incidence of knee ligament injuries three times as high compared to other areas. Since 1986 we have evaluated 206 patients operated for knee ligament injuries, 44% with unidirectional and 56% with multidirectional instabilities. We report about the preoperative data.

[Skier's thumb injury in the child]. / Die Skidaumenverletzung beim Kind.

Acute rupture of the ulnar collateral ligament (UCL) of the metacarpophalangeal joint of the thumb (skier's thumb) is a common skiing injury in adults. Do we find this injury in children? Of the 302 skier's thumbs during the last 4 years we found 24 (8%) injuries in children (mean age 13.4 years) with open growth plates. They had the following diagnosis and consecutive treatment: 5 partial ruptures of the UCL, 3 Salter I and 6 Salter II fractures with radial fragment of the proximal phalanx I; all these had conservative treatment. In addition one had a Salter III fracture with open reduction and fixation, 6 avulsion fractures, which were treated twice operatively and 4x conservatively and 3 ruptures of the ligament which needed reconstruction. Supposing the trauma mechanism in adults, we see a different, age-dependent injury pattern in children. The younger had Salter-I- and Salter-II-lesions of the proximal phalanx, where as the adolescents showed avulsion fractures and ruptures of the UCL as seen in adults. The follow-up of 17 cases minimally 1 year after the accident showed in 12 a full recovery, in 4 cases small subjective symptoms but full function and in 1 case an ankylosis of the MCP-joint following a postoperative infection.

Skier's thumb--the significance of bony injuries.

In a retrospective study to determine the anatomic nature of injuries in thumbs that were treated surgically for either fracture or instability, we reviewed 63 consecutive patients with acute skier's thumb injury. Of the 63 thumbs, 25 (40%) had a fracture. Surgical exploration showed 2 fracture types: a fragment that was attached to the ulnar collateral ligament, and a fragment that was not attached to the ulnar collateral ligament. The 1st type, corresponding to true avulsion fracture of the ulnar collaternal ligament, was found in 8 cases; the same fracture type was seen in another 7 cases, with an isolated fragment that was not attached to the ligament. Such an isolated fragment was observed in 10 other cases in which the ulnar collateral ligament was completely disrupted. This type of bony fragmentation cannot be differentiated from a bony avulsion of the ulnar collateral ligament on routine films. Therefore, stress testing the injured thumb is mandatory even when bony avulsion fracture with minimal displacement is suspected from a radiograph, as indeed the fracture may not be a bony avulsion but may be a fragmentation of the ulnar volar aspect of the proximal phalanx associated with a complete disruption of the ulnar collateral ligament.

[A new self-repositioning technique for fresh, anterior-lower shoulder dislocation]. / Eine neue Selbstrepositionstechnik der frischen, vorderen-unteren Schulterluxation.

In case of a shoulder dislocation there is always a question of a safe and atraumatic reduction technique if possible without analgetics or even general anesthesia. The dislocated humeral head is reduced anatomically with the help of the patient's own body weight under muscular relaxation without injuring manipulations. Even with displaced fractures of the greater tuberosity or an impression fracture of the humeral head successful reductions were obtained. We have been using this method for over three years with a primary success rate of over 60%.

[Surgical technique in ski thumb injury]. / Operationstechnik einer Skidaumenverletzung.

The skier's-thumb, an instability of the ulnar collateral ligament (UCL) of the first metacarpo-phalangeal joint is one of the most common hand injuries in alpine skiing. In over 60% of our cases the ligament is ruptured, mostly near or at its distal insertion at the base of the first metaphalanx. Also a bony avulsion of the UCL at its distal insertion is not uncommon. A significant instability or a bony avulsion of the UCL with dislocation of the fragments is an indication for open reconstruction and stabilization. Good experience has been gained with a fish hook pull-out-wire technique. We describe the approach and the reconstruction technique.

[Patient information in surgery]. / Patienteninformation in der Chirurgie.

In a prospective study 50 patients undergoing a hernia repair were asked their opinion about an information sheet which was given to them preoperatively. For 94% this paper is of help; for 82% the written information has to be clarified by an additional personal talk with the doctor. Another possibility, especially good for visualisation, is the video. At the hospital of Davos there are at the moment 7 clips available to explain the treatment and the aftercare after an operation or conservative therapy in traumatology.

[Laparoscopic cholecystectomy]. / Die laparoskopische Cholezystektomie.

In a community-hospital the problem arises how to improve the knowledge and skill of the surgeons. As mentioned, for some reasons the possibility of training outside the hospital is limited. We get closer to that problem by operating these cases together: two surgeons of two hospitals next each other. An example to describe this problem is the laparotomic cholecystectomy.

[Complex internal knee lesions--diagnosis, indications and timing]. / Komplexe Kniebinnenläsion--Diagnose, Indikation und Timing.

Ligamentous knee injuries are nowadays more often seen in the office of the family physician, mainly because of an increase in recreational sports injuries. With the help of a questionnaire one can obtain a reliable impression of the injury pattern. The clinical examination is performed in a standardized way, so even in acute ligamentous injuries a correct diagnosis can be obtained at the first examination. The diagnosis of an instability is made with an accurate clinical examination; in case of marginal cooperation of the patient the examination is performed under anesthesia. Depending on the findings, the definitive operation will follow at the same time. In case of a big hemarthrosis we recommend an a.-p. and a lateral X-ray of the knee joint for exclusion of a bony injury before proceeding with the clinical examination. An arthroscopy is indicated in effusions of unclear origin, in the suspicion of meniscal or cartilaginous damage, in a stable knee with hemarthrosis and before definitive stabilization of complex injuries to exclude further damage to other intraarticular structures. Acute ACL ruptures are only operated on in case of bony avulsion fractures, in persons very active in sport and in case of relevant concomitant injuries. Medical collateral injuries without an ACL rupture are usually treated conservatively, except if there is an additional peripheral tear of the meniscus. PCL injuries are seldom operated, except if there is a complex concomitant instability. We aim for an early reconstruction within two weeks after the accident.

[Preoperative arthroscopy in fresh complicated internal knee lesions]. / Präoperative Arthroskopie bei frischen komplexen Kniebinnenläsionen.

In a prospective study, 197 preoperative arthroscopies were carried out on 194 patients with fresh severe internal lesions of the knee. The injuries are analyzed, with reference in particular to diagnosis and treatment of additional meniscus lesions. Advantages and disadvantages of the procedure are discussed.

[Preoperative arthroscopy in fresh complex internal knee injuries]. / Präoperative Arthroskopie bei frischen komplexen Kniebinnenläsionen.

With reference to a prospective study 197 preoperative arthroscopies were carried out on 194 patients with fresh severe internal lesions of the knee. The injuries are analysed, in particular diagnostic and treatment of additional meniscus lesions. Advantages and disadvantages of the procedure are discussed.

[Special positioning aids in fractures and dislocations of the spine]. / Spezielle Lagerungshilfen bei Frakturen und Luxationen der Wirbelsäule.

Early recognition of spine injuries is of outmost importance. In the case of suspected fractures and in all severe skull injuries, a careful approach and careful positioning of the injured patient is mandatory. Immobilization of the spine is the prime concern during transportation of trauma patients to prevent neurologic compromise. We prefer the supine position on a stable support. In the case of cervical spine injury, immobilisation with a cervical collar in extension is necessary. Definitive transportation should be performed on a vacuum mattress supported by a scoop-stretcher. In fractures of the thoraco-lumbar spine, a lordotic support with a soft pillow is recommended.

[Meniscus ultrasound--a reliable way for diagnosis of meniscus lesions?]. / Meniskus-Sonographie--ein sicherer Weg zur Diagnose von Meniskusläsionen?

Controversies exists about the value of sosgraphy in diagnosis of meniscal injuries. We therefore examined 179 knee joints. In a prospective study of 177 patients with knee problems, ultrasound was utilized to assess its values as a screening tool for meniscal tears. Prior to the arthroscopy the menisci were scanned from an independent team by using 7.5 and 10.0 MHz ultra-sound waves. 113 meniscal tears were seen at arthroscopy; 22% of these tears could not be detected by scanning (false negative results) while 10% of intact menisci showed positive echogenic structures analysed as meniscal tears. The results showed a sensitivity of 30.0% and a specificity of 85.3%. We cannot share the opinion of some autors that ultrasound is a reliable means of accurately diagnosing meniscal tears. It seems that ultrasound scanning of the menisci is still a experimental method without any clinical importance.

[Preoperative arthroscopy immediately before reconstruction of internal knee injuries]. / Präoperative Arthroskopie unmittelbar vor der Rekonstruktion von Kniebinnenläsionen.

With reference to a prospective study 197 preoperative arthroscopies were carried out on 194 patients with fresh severe knee injuries. The injuries are analysed, in particular for diagnosis and treatment of additional meniscus lesions. Advantages and disadvantages of the procedure are discussed.

[Arthroscopically guided osteosynthesis of lateral tibial plateau fractures]. / Arthroskopisch kontrollierte Osteosynthesen lateraler Tibiaplateaufrakturen.

A prospective study was performed on 16 patients with lateral tibial plateau fractures. All injuries were associated with alpine or cross country skiing. Included in the study were those patients with a 2 mm or greater articular surface depression with radiographic findings consistent with the AO/ASIF classification of tibial plateau fractures, 41 B2.2./B3.1. A combined procedure was performed with arthroscopic visualization of the knee joint and utilization of a cannulated plateau elevator. All fractures were reduced with this device with subsequent autogenous bonegraft and when indicated, transverse cancellous lag screw fixation. Followup was from 1 to 6.5 years for the 15 patients with all but two reporting resumption of activity to pre-injury levels.

[Epidemiology, treatment and follow-up of acute ligamentous knee injuries in Alpine skiing]. / Epidemiologie, Behandlung und Verlaufsbeobachtung frischer ligamentärer Kniebinnenverletzungen im alpinen Skisport.

In Switzerland the incidence of sport injuries is twice as high as traffic injuries. Soccer and alpine skiing are the major reasons for such injuries. Nowadays one out of four skiing injuries is an injury of the knee ligaments. Especially in skiing areas favored by beginners, we observed an incidence of knee ligament injuries three times as high compared to other areas. Since 1986 we evaluated 206 patients which were operated for knee ligament injuries. In 44% the direction of instability was unidirectional, most of them in the anterior direction. 115 patients had combined instabilities, 86% of those were anteromedial. 179 patients (87%) were followed up for at least 20 months. The knee was evaluated with the scoring system of the OAK (Orthopädische Arbeitsgruppe Knie der Schweizerischen Gesellschaft für Orthopädie) and judged by four criterias (pain/swelling; movement/force; stability and function). As expected, unidirectional instabilities show better results than multidirectional. The mean value of the total score for isolated medial collateral injuries was 95.3 of 100, for isolated anterior instabilities 90.4 and for combined antero-medial instabilities 86.7 Altogether 2/3 of the patients showed very good results in stability but, 4/5 showed good results in function, so 4/5 of the patients and their physicians considered the final result as good to very good and 2/3 of those patients are back to sports, only two percent do no more sports at all.