[The osteosynthesis of fractures of distal radius with the AO/ASIF Titanium Pi Plate]. / Osteosynthese distaler Radiusfrakturen mit der AO/ASIF Titan-Pi-Platte.

The AO/ASIF Titanium Pi Plate has been developed for dorsal plating of fractures of the distal radius. It is designed by reflection of the anatomy, to ensure stability of the angle using a juxtaarticular band and to minimize tissue reaction by low profile design. The aim of this study was to evaluate the subjective and objective outcome of 61 consecutively operated patients after a minimum of 12 months (12-29 months) postoperatively. There were 3 A2, 23 A3, 1 B1, 12 C1 and 22 C2 fractures (AO-Classification). The subjective results were good to very good. The range of motion showed over 80% compared to the uninjured side. Overall, there were no ruptures of tendons and 18% irritations. Extension, ulnar abduction and force were significantly better in patients in which the plate has been removed. In this collective the tendon irritations were only 3.8%. With the AO/ASIF Pi Plate good subjective and objective results can be achieved. The indication for removal of the plate should be given generously.

[New surgical treatment procedures in fractures of the distal tibia (LCP, MIPO)]. / Neue Stabilisierungsverfahren bei distalen Tibiafrakturen (LCP, MIPO).

All along the operative treatment of distal tibial fractures is a difficult procedure. In most cases the clinical situation is characterized by small distal fragments in combination with crucial soft-tissue conditions. That's why complications as primary or secondary displacements, mal unions, delayed or non unions and as well as a high rate of deep wound infection are often seen. Thus internal fixations with traditional implants (standard screws and plates) could consider inevitable this crucial biology and biomechanics only insufficiently. The nowadays available internal fixators with optional angular-stable screws expand the possibilities of internal fixation in these severe situations. Their minimal invasive application (MIPO, Minimally Invasive Plate Osteosynthesis) takes care of the soft tissue and reduces the surgical trauma furthermore. With the variety of their possible applications (combination of angular stability with standard application) also the demands increase, however, both onto the surgeons, but also onto the general practitioners in the aftercare. The combination of most different tactics in one implant results in the consequence, that at the same bone simultaneously direct and indirect bone healing will be expected. The radiological differentiation between desired and unwanted healing processes becomes thus difficult. Pre- and perioperative procedures require from the trauma surgeon a huge infrastructure and a high measure of biomechanical and biological experience. In the postoperative management of these injuries an unlimited cooperation between traumatologists and general practitioners is indispensable for a further successful course.

[Timing of the surgery of rupture of the anterior cruciate ligament. Effects of acute or delayed surgery on arthrofibrosis rate and work disability]. / Operationszeitpunkt bei der vorderen Kreuzbandruptur. Beeinflussung der Arthrofibroserate und der Arbeitsunfähigkeit durch akute oder sekundäre Operationen.

The optimal time to perform acute ACL reconstruction with respect to arthrofibrosis is discussed. Most authors prefer delayed surgery. The definition of the term "acute" varies between 48 hours and 4 weeks. In this study the limit was set at 60 hours. Acute ACL reconstruction was performed in 39 patients and delayed surgery in 35 patients after they had regained full ROM. The incidence of arthrofibrosis was not higher in the acutely operated group whereas overall inability to work was 44% lower in this population. When the indication is clear, we think that acute ACL reconstruction may be performed within 60 hours without a higher risk of postoperative development of arthrofibrosis. Nowadays, this strategy should also be considered for economic reasons.

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.

[Long-term peridural anesthesia and minimally invasive therapy of arthrofibrosis of the knee joint]. / Langzeit-Periduralanästhesie und minimalinvasive Therapie der Arthrofibrose am Kniegelenk.

We report on our experiences with continuous epidural anesthesia after arthrolysis of the knee joint. The restoration of knee motion is the main goal of our treatment regimen which includes daily passive full mobilisation of the knee joint with a continuous epidural catheter after arthroscopic lysis and a functional after treatment with full weight bearing. From December 1992 to November 1996 32 arthroscopic lysis have been performed at the Surgical Department of Triemli Hospital in Zürich, Switzerland. The indications for prior knee surgery included 22 ACL reconstructions, 4 sustained fractures about the knee and 6 miscellaneous etiologies. Arthroscopic lysis was performed for any failure in improving knee motion despite intensive physical therapy. According to Gassen et al. [4] we found one (3.1%) very severe, 5 (15.6%) severe, 12 (37.5%) moderate and 14 (43.8%) minor cases of arthrofibrosis. After 8 months on average, a second lysis had to be performed in six cases. All had an ACL reconstruction as prior surgery, in four out of these six patients only physiotherapeutic after treatment was performed after the first lysis, 2 patients developed a symptomatic patella baja. At the end of the treatment after 10 months on average, 16 (50%) cases showed a very good, 7 (22%) a good, 5 (16%) a satisfactory and 4 (12%) a poor result concerning range of motion. We think that a daily passive full mobilisation under regional anesthesia with a continuous epidural catheter is the key to hold the intraoperatively reached range of motion especially for moderate to very severe cases of arthrofibrosis.

Modified Elmslie-Trillat procedure for instability of the patella.

The purpose of this study was to determine whether or not the modified medial transfer of the ligamentum patellae in case of objective instability of the patella is an adequate therapy and if it is possible to improve the patellar congruence angle by this method. Between October 1987 and April 1993, 41 operations were performed in 37 patients with medialization of the medial third of the ligamentum patellae with the corresponding part of the tibial tubercule. Four patients needed a bilateral operation; the two interventions were not performed at the same time. Thirty-six operated knees (88%) were examined at a median clinical and radiological follow-up of 62.8 months (+/- 15.8 SD). For evaluation, the objective and subjective Turba score was used, and pre- and postoperative X-rays were compared. The patients' average age at the time of intervention was 23.2 years (+/- 7 years SD). The operation was performed 39 times for recurrent dislocation or subluxation, for patella alta with cartilage tissue damage, and for first time traumatic dislocation. The only postoperative complication was a temporary peroneal paresis. There were no redislocations seen at the follow-up. One patient with repeated subluxations underwent an additional lateral release combined with a repair of the medial retinaculum. In all other cases, the Turba score showed good or excellent results (subjective 1.9; objective 0.8), the patellar congruence angle was significantly improved (P < 0.001), and there were no medial subluxations. We conclude that the transfer of the medial third of the ligamentum patellae for objective instability of the patella is a minimally invasive and adequate technique to improve significantly a pathological patellar congruence angle.