Surgical treatment of acute acromioclavicular joint dislocations: hook plate versus minimally invasive reconstruction.

PURPOSE: This study was performed to compare the clinical results of a minimally invasive technique for acute acromioclavicular (AC) joint dislocation repair with the traditional hook plate fixation. METHODS: Forty-four patients with an acute (within 2 weeks after trauma) complete AC joint separation (35 male, nine female; median age 36.2 years, range 18-56) underwent surgical repair with either a minimally invasive AC joint repair or a conventional hook plate. Functional outcome was evaluated using the Constant-Murley Score (CMS), the TAFT score and the AC joint instability score (ACJI). Radiographic evaluation was performed with bilateral anterior-posterior (a.p.) stress and Alexander views. RESULTS: All patients were available after a median follow-up of 32 months (range 24-51). There were no significant differences in the mean CMS, Taft score and the ACJI between the two groups. The radiological assessment revealed no significant difference in the coracoclavicular distance. In both groups, a slight loss of reduction was observed. Periarticular ossification was seen in 11 patients of the minimally invasive AC joint repair and eight patients of the hook plate group but this did not affect the final outcome. Hook plates were removed after a median interval of 11.9 weeks (range 10-13). CONCLUSION: Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation. However, in the hook plate group a second operation is mandatory for plate removal. LEVEL OF EVIDENCE: III.

[Anatomic reconstruction of the anterior cruciate ligament in single bundle technique]. / Die anatomische Ersatzplastik des vorderen Kreuzbands in Einzelbündeltechnik.

OBJECTIVE: Restore the knee stability by ACL reconstruction of the anterior cruciate ligament. INDICATION: Acute and chronic functional instability with rupture of the anterior cruciate ligament giving way phenomena, acute rupture of the anterior cruciate ligament with concomitant meniscus repair. CONTRAINDICATIONS: Local infection in the knee joint, local soft tissue damage, lack of cooperation of the patient. SURGICAL TECHNIQUE: The operation begins with the examination under anesthesia. It follows an arthroscopic examination of the knee and the arthroscopic treatment of accompanying intra-articular lesions (meniscus and cartilage damage). The semitendinosus tendon is harvested via a 3 cm skin incision medial to the tibial tuberosity. A four stranded tendon graft is prepared with a minimum length of 6.5 cm. Alternative grafts for this technique are the patellar tendon, quadriceps tendon, and allografts. The femoral tunnel for the ACL graft is drilled via a deep anteromedial portal under arthroscopic control. For precise placement of the guide wire a specific offset aimer is used. For drilling the knee must be flexed more than 110°. Landmarks are the intercondylar line and the cartilage-bone interface. The position of the guide wire is always controlled by the medial portal (medial portal view). The guide wire is overdrilled with a cannulated drill (4.5 mm when a flip tack is used). The drill diameter for the 30 mm long blind tunnel is chosen according to the graft diameter. A gentle tunnel preparation may be achieved with the use of dilators. At the tibia, the anterior horn of the lateral meniscus is used as a landmark in the absence of ACL stump. The guide wire is first overdrilled with a 6 mm drill. Slight adjustments to the tibial tunnel location can be archieved when the guide wire is overdrilled eccentrically with a larger drill. At the femur an extracortical fixation technique with a flip button is preferred. At the tibia, a hybrid fixation with absorbable interference screw and button is used. REHABILITATION: The rehabilitation program is divided into three phases. During the inflammatory phase (1st-2nd week) control of pain and swelling is recommended. The patient is immobilized with 20 kg partial weight bearing. During the proliferative phase (3 nd-6th week), load and mobility are slowly increased. Goal of this phase is it full extension. Exercises should be performed in a closed chain. During the remodeling phase strength and coordination exercises can be started. Athletes should not return to competitive sports before the 6th to 8th month. RESULTS: In a prospective study, we have examined 21 patients treated with an anatomic anterior cruciate ligament reconstruction in single-bundle technique, after two years. As graft the semitendinosus was used. The postoperative MRI diagnosis showed that all tunnels were positioned anatomically. KT 1000 measurement showed that the difference of anterior translation decreased from an average of 6.4-1.7 mm. A sliding pivot shift phenomenon was detected in only one patient. The postoperative Lysholmscore was 94.2 points.

[Arthroscopic arthrolysis of the elbow joint]. / Die arthroskopische Arthrolyse des Ellenbogengelenks.

OBJECTIVE: Arthroscopic assisted improvement of range of motion in elbow stiffness. Detailed diagnostic evaluation including medical history and preoperative radiographs, CT and MRI scans are necessary for planning the operative treatment. INDICATIONS: Restricted range of motion < 30° in extension and/or more than 100° in flexion related to intraarticular causes (loose bodies, osteophytes or contracture of the capsule). CONTRAINDICATIONS: Extension deficit > 30°, extraarticular causes (e.g., heterotopic ossifications), nerve irritation, incongruity of joint surfaces, acute joint infection. SURGICAL TECHNIQUE: Prone position, filling of the joint with irrigation fluid, arthroscopic examination of the anterior and posterior compartment. Partial synovectomy, debridement and capsular release, removal of loose bodies and resection of osteophytes. POSTOPERATIVE MANAGEMENT: Intensive physiotherapy, continuous passive motion. Plexus anesthesia and nonsteroidal antiphlogistic medication. RESULTS: A total of 29 patients who underwent arthroscopic arthrolysis of the elbow joint were evaluated after a mean follow up of 15.4 months after surgery. Average preoperative extension deficit improved from 23° to 5°. Mean preoperative flexion improved from 115° to 131°. Improvement of range of motion was 34° on average. No vascular or neurologic complications were noted. Infection was not observed. In one case, stiffness persisted and early arthroscopic revision was needed. Postoperative patient satisfaction on the VAS Scale was 8.9. The Mayo Elbow Performance Index was 92.9 points on average.

[Unicompartimental joint (Oxford III) with mobile bearing : Minimally invasive implantation of a in the medial compartiment]. / Unikompartimentelle Oxford-III-Prothese mit mobilem Gleitlager : Minimal-invasive Implantation im medialen Kniegelenkskompartiment.

OBJECTIVE: Replacement of the joint surfaces in the medial compartment by an endoprothesis with a mobile bearing. INDICATIONS: Unicompartimental anteromedial gonarthrosis with an intact anterior cruciate ligament. Avascular necrosis at the medial femoral condyle. CONTRAINDICATIONS: Third to fourth degree cartilage damage in the lateral compartment. Lateral menisectomy. Symptomatic osteoarthritis in the femoropatellar joint. Chronic polyarthritis. More than 15° varus. Varus passive not redressable. Medial or lateral subluxation. More than 15° extension deficit. Passive flexion less than 110°. Cruciate ligament lesions with instability. Poor soft tissue conditions. SURGICAL TECHNIQUE: The leg is mounted on an electric leg holder that allows flexion up to 120°. The joint is opened via an anteromedial arthrotomy starting at the medial border of the patella and ending 3 cm below the tibia plateau. The osteophytes are resected and the tibial resection is performed with an oscillating saw under guidance of a jig which is positioned according to the physiological tibial slope. The medial collateral ligament must be protected with a Hohmann retractor. The vertical cut is performed first; then the horizontal cut is performed. The size of the resected plateau should allow space for a tibial component and a meniscus implant of 4 mm. The resected plateau seves to determine the size of the plateau. The jig for the femoral preparation is adjusted according to the axis of femur and tibia. After the posterior resection the 0 mm spigot is inserted into the central drill hole and the distal part of the condyle is milled. The depth of milling is determined by equalizing the flexion and extension gap. Extension and flexion gap balancing is controlled with test inlays. Posterior osteophytes at the medial femur condyle are cut with a special chisel. In the anterior aspect bone resection is needed to prevent impingement of the meniscus implant. Then the tibia plateau is finally prepared. After inserting the test implants the femoral and tibial components are cemented in one or two stages. POSTOPERATIVE MANAGEMENT: The patient is mobilised under full weight bearing with two crutches. RESULTS: A total of 50 Oxford III hemiarthroplasties were implanted using the minimal invasive technique. Indication was an anteromedial gonarthrosis with intakt anterior cruciate ligament. Age varied between 59 and 79 years with a mean of 71 years. Follow-up was 5 years. There were three revisions till final follow-up. Cause was an inlay luxation in one case and in two cases with lateral arthrosis. The average KOOS score was 92.3 points (± 6 points).