Diagnosis of knee instability using sonography

OBJECTIVE: A sonographic method has been developed to diagnose knee joint instabilities and to gain exactly quantifiable and reproducible measurements. DESIGN: Based on biomechanical considerations, a new positioning device to analyse knee instabilities sonographically has been developed and tested in in vivo studies. BACKGROUND: Common instrumental testing techniques are difficult to reproduce and show a lack of reliability. METHOD: Using sonography the cortical line of the femur and tibia are observed. At the same time a translation of these two partners at the knee joint is provoked in a defined position using the special holding device and under a defined amount of stress. Using this method 142 healthy people, placed in different age groups, were tested to establish standard values for the physiological knee joint translation. A prearthroscopic stability analysis was performed on 101 patients. RESULTS: This study proves that the special device developed, together with the technique used, provides reliable and exact measurements for knee instability in different translation directions. In healthy subjects the lateral compartment always showed a larger translation than the medial compartment. A gradual increase in translation was determined in the age groups over 30 years. A significant difference of 0.0001 was shown between knee stability and instabilities. Moreover, a further differentiation between partial and total ACL ruptures and chronic instabilities was determined. This provides an important advantage not offered by usual instrumental testing techniques. CONCLUSIONS: The ability to diagnose even a very low extent of instability and to differentiate between different kinds of instabilities enables exact controls to be carried out for both conservative and operative treatment.

Local instillation therapy in cervical syndroms

Injection therapy is highly significant in the treatment of cervical syndromes. Following the differential diagnosis and analysis of the symptoms, injection treatment leads to a worthwhile degree of pain relief as a result of the anaesthetic effect on the nerve. This paper describes the general criteria for such treatment and also the various of injection techniques in use.

[Injection therapy in cervical syndromes]

Injection therapy is highly significant in the treatment of cervical syndromes. Following the differential diagnosis and analysis of the symptoms, injection treatment leads to a worthwhile degree of pain relief as a result of the anaesthetic effect on the nerve. This paper describes the general criteria for such treatment and also the various injection techniques in use.

[Ultrasound morphologic criteria in evaluating meniscus changes--an experimental study]

Experimental data and clinical experience with ultrasonography have demonstrated good results in the evaluation of internal derangements of the knee. But the value of ultrasound of the menisci still is controversial. The following investigations compare sonography with histologic results. In a water bath 64 cadaveric menisci were examined with a 5 MHz phased array sector scan. Pathologic conditions like natural or artificial tears, meniscal degeneration and crystal deposition diseases gave different echoes. In cases of vertical meniscal tears, a sharp and bright line-echo is seen on the screen. Due to this consistent reflexion, different types of meniscal tears cannot be differentiated by ultrasound. Severe degrees of meniscal soft tissue degeneration, proven histologically, were shown as hypoechoic areas. Following this experimental results, sonography is a useful modality in the diagnosis of meniscal disorders.

Endoscopic therapy in epicondylitis radialis humeri

After making an exact diagnostic verification of tennis elbow and after intensive conservative treatment has been used without any signs of improvement, the Hohmann operative procedure involving the incision of the proximal extensor tendon has distinct advantages as far as the pathophysiological aspects are concerned. This operative treatment can be safely carried out using endoscopy. A normal 30 degrees endoscope, nonelectrolyte fluid, an exploratory probe, and an electrotome are necessary. The procedure is described in detail.

[Basic problems in the treatment with functional knee orthoses]

An indication for functional knee-orthoses is given especially with ACL-insufficiency and after ACL-operations. Analyses of biomechanical examinations demonstrate difficulties in realizing the joint movement of the knee in detail and imitating it with knee-orthoses. An anamnestic investigation and clinical examination of sportsmen and -women, using functional knee-orthoses due to ACL-insufficiency (24 Lenox-Hill, 25 C.Ti., 38 Donjoy), demonstrate problems in practical usage of these orthoses. Problems especially arise from dislocation of the orthoses' joints and a deficient protection against anterior tibial translation. Thus leading to evident giving-way events though using a knee brace in 68% of these cases. In the tested knee-orthotic-devices problems in usage are independent of the kind of mechanical joints of the orthoses. The clinical examination should prove an application of the orthosis without pressure and only little distal dislocation.

[Clinical and sonographic meniscus diagnosis]

Clinical examination still plays an important role in diagnosing meniscal tears. The types of sensitive nerves in the knee joint are responsible for nonspecific pain, which is often correlated with too little specificity in meniscal tests. Ultrasound examination of meniscal structures of the knee joint has been debated extensively in recent years. Criticism of this noninvasive technique was due to small patient groups, improper technical and inaccurate manual standards. Since 1988 ultrasound of the tibial meniscus has become a standard technique in our Department of Orthopaedic Surgery with defined criteria of the intersecting plane and evaluation of ultrasound images. A prospective follow-up study during 6/1988 and 5/1993 including 1186 ultrasound examinations before arthroscopy, was performed. The sensitivity for ultrasound of the lateral meniscus was 58% and for the medial meniscus 83%. Specificity with 98% for the lateral and 90% for the medial meniscus was good. Sonographic detection of meniscal tears depends on the shape and location of meniscal tears. This has been shown by experimental studies in cadavers. A follow-up study including 113 knee joints was performed to prove the value of clinical and ultrasound examination in relation to arthroscopy. The sensitivity of sonography for medial meniscus was 81% and 40% for the lateral meniscus. Although the sensitivity of the clinical examination was 81% (medial) and 47% (lateral), the low specificity of 70% for meniscus tears indicated that it was because of false-positive clinical evaluation of meniscal disorders. In young patients with reflectory muscle spasm and those with acute trauma of the knee joint, clinical examination of the meniscal structures showed poor results. In these cases, too, ultrasound examination showed advantages. Ultrasound of the knee joint meniscus is noninvasive, reproducible and low cost. In cases of uncertain clinical results, ultrasound offers a good opportunity to visualize meniscal disorders.

Significance of laser treatment in arthroscopic therapy of degenerative gonarthritis. A prospective, randomised clinical study and experimental research

To ascertain the efficiency of different techniques of arthroscopic therapy for gonarthritis and establish the relevance of the extent of chondromalacia, clinical and experimental studies were performed. In principle, the process of chondromalacia determines the course of the disease. Treatment of additional meniscus lesions temporarily leads to better clinical results, but after only a few months the symptoms caused by the arthritic process reappear. Compared with the temporary relief of complaints after debridement and lavage, smoothing with a xenon chloride excimer laser in grade II chondromalacia leads to statistically significantly better clinical results. Scanning electron microscopic studies confirm the extremely good smoothing. These studies permit clear statements as to the various methods of treatment and their application in the different grades of chondromalacia, thus leading to differentiated arthroscopic treatment of degenerative gonarthritis.

[Osteochondral fracture of the lateral tibial pilon]

In this paper we report a case of osteochondral fracture of the lateral tibial pilon. A young man fell while he was playing soccer. In the following months the ankle was swollen and painful. Later the reason for his ankle pain was clearly visible on the X-ray pictures, which revealed a severe osteochondral fracture of the lateral tibial pilon. We describe the arthroscopic and X-ray grading of osteochondral fractures of the ankle and their treatment.

[Characteristics of an intervertebral disk herniation in spondylolisthesis]

Treatment of intervertebral disc herniation associated with spondylolisthesis is not different from common procedures concerning indication for surgery and surgical technique as far as sciatica is not related to retrolisthetic soft tissue or the posterior edge of the vertebral body. In a case of a disc herniation L5/S1 and an olisthesis grade I with radicular pain L5 a microdiscectomy of the prolapse and parts of the retrolisthetic soft tissue was performed. An immediate reintervention was necessary due to postoperative symptoms of paralysis. Derangement of the retrolisthetic soft tissue was found to cause the increased L5-symptoms.

[Sonographic studies of the lateral ligament of the proximal ankle joint in recent ligament rupture and chronic ligamental instability]

For diagnosis of instability in case of ruptures of the lateral ankle joint ligaments a special ultrasound examination technique was established. In 41 patients with acute ruptures and 8 patients with chronic instabilities a prospective preoperative sonographic instability-testing was performed and compared to intraoperative result. A sensitivity of 0.96 for injuries of the lig. fib. tal. ant. and 0.79 for the lig. fib. calc. proves the exactness of this method. This technique is easy to perform and the result can be documented. This examination is accepted by the patients.

[Instrumental and technical prerequisites for arthroscopic surgery of the knee joint]

The continuous improvement of intrumentation and equipment is the reason for the steady increase in arthroscopic operations. As the technical equipment is becoming increasingly complicated, attention must be paid to training and standardized procedures in order to ensure that the arthroscopic operative procedure is fast, safe, and without complications. Special operative techniques and instruments have been approved for clinical use, depending on the arthroscopic operation.

[Follow-up following Lelièvre's method of metatarsal head resection]

From 1975 to 1987 on 107 cases of severe deformities of the forefoot a resection of the metatarsal heads according to the method of Lelièvre was performed. As to the success of this method special features of this operation and especially the requirements of postoperative treatment will be explained. Possible complications of healing will be detailed. The procedure of resecting the heads of the metatarsal bones according to Lelièvre seems to be recommendable in order to prevent immovability, especially in case of advanced inflammable alterations of the joints in the forefoot.

[Torsion effects of shoe soles. A biomechanical viewpoint]

Requirements concerning the location of the top of shoe-sole rolls are formulated on the basis of the physiological sequence of movements in the step, the aim being to ensure a functionally correct sequence of movements, corresponding to the condition to be treated. Special attention should be paid to adverse torsion effects caused by inappropriate positioning of the rolls, since the torsion has negative effect on the gait pattern.