[Implant-free replacement of the anterior cruciate ligament with the double bundle technique: a modification of Pässler's operation technique]

Reconstruction of the anterior cruciate ligament using the double bundle technique provides better covering of the anatomic insertion site areas and fiber length change behavior. Biomechanical studies and intraoperative measurements with computer navigation systems document increased stability in particular due to rotational stability. To date the impact of the posterolateral bundle is questioned and clinical studies have reported divergent outcomes. In favor of enhanced rotational stability, some techniques leave the basic principles of aperture or central graft fixation, decreasing primary stability and running the risk of tunnel widening especially on the femoral site. Additional use of interference screws means increased implants and costs and bone void in cases of revision is challenging. A technique for anatomic double-bundle reconstruction without the use of implants is presented, which allows for femoral aperture fixation with high primary stability of both bundles. In terms of the knot/press-fit technique of Paessler in the U-shaped tendons, a knot is created at the free end, which serves as a rigid press-fit anchoring in bottleneck shaped femoral drill holes at the insertion site of the anteromedial and posterolateral bundles. The drill holes are prepared in flexion of 110-115 degrees using common offset and target drill devices. Mersilen tapes are applied to introduce the grafts from femoral to tibial and to fix the tendons over a bony bridge on the tibial site after preconditioning. The gracilis tendon mimics the posterolateral bundle and is fixed in 20 degrees of flexion, the semi- tendinosus tendon is used for the anteromedial bundle and is fixed in 40 degrees of flexion. The advantages of the presented technique are the central, rigid femoral anchoring without hardware, the thin bone tunnels which show no tunnel widening and allow for an optimal bone tendon contact to enhance bony ingrowth. The technique is cost-efficient and provides anatomic double bundle reconstruction of the anterior cruciate ligament. The sacrifice of hardware ensures easy revisions. The disadvantages are the peripheral tibial fixation, the preparation of the tendons needs tendon length and the creation of tendon knots providing high stability requires practice. The two femoral bone tunnels have proved to be safe regarding the stability of the lateral femoral condyle.

Posttraumatic anterior-inferior instability of the shoulder: arthroscopic findings and clinical correlations

INTRODUCTION

The main purpose of our study was to evaluate intra-articular lesions in glenohumeral-instability with arthroscopy and correlate them with clinical findings as well as history of instability.

MATERIAL AND METHODS

In this prospective multi-centre study, we evaluated arthroscopic findings in 303 patients with posttraumatic anterior-inferior instability of the shoulder. The study cohort was divided into 2 groups: patients with a history of one dislocation (Group 1, n=61, 20.1%) and patients with a history of more than one dislocation (Group 2, n=242, 79.9%).

RESULTS

In Group 1, 37 patients had an IGHL-lesion, 31 a MGHL-lesion and 41 a Hill-Sachs lesion. In Group 2, 182 patients had an IGHL-lesion, 172 a MGHL-lesion and 203 a Hill-Sachs lesion. The percentage of lesions in Group 2 (IGHL-75.2%, MGHL-71.1%, Hill-Sachs-83.9%) was significantly higher than in Group 1 (IGHL-60.7%, MGHL-50.8%, Hill-Sachs-67.2%, P=0.0233, P=0.0026, and P=0.0033, respectively). Within Group 2 we found significantly more Hill-Sachs-lesions with a history of an increasing number of recurrences (P=0.0436). We also found an increase of IGHL- and MGHL-lesions with an increasing number of recurrences, but this difference was not significant. The distribution of lesion types of the anterior labrum-ligament complex showed no significant difference between the two groups, apart from a higher incidence of ALPSA-lesions within Group 2 (34.7% versus 18.0% in Group 1). The results of this study show that recurrences after primary posttraumatic anterior-inferior shoulder dislocation cause increasing ligamental damage as well as increasing Hill-Sachs lesions within the gleno-humeral joint.

CONCLUSION

Thus we conclude that early surgical stabilization after posttraumatic anterior-inferior shoulder dislocation is necessary to prevent increasing damage within the shoulder joint.

Primary stability with tibial press-fit fixation of patellar ligament graft: An experimental study in ovine knees

PURPOSE

To investigate the initial fixation strength and to assess the value of tibial press-fit fixation of the bone-tendon-bone graft in anterior cruciate ligament reconstruction.

TYPE OF STUDY

Nonrandomized control trial.

METHODS

For tibial press-fit fixation, the tibial bone block of the bone-tendon-bone graft is countersunk in a bony groove at the distal tunnel outlet and fixed over a bone bridge with 2 No. 6 Ethibond sutures. The bone cylinder harvested from the tibial tunnel using an oscillating hollow saw is plugged into the tibial tunnel parallel to the graft, thus providing for additional anchoring of the graft by tibial press-fit fixation. In a comparative experimental study in 46 ovine knees, this fixation method was assessed for its value in anterior cruciate ligament reconstruction. A tibial bone tunnel was placed in routine manner in each ovine tibia using a target drill unit and an oscillating hollow saw. The complete patellar ligament, proximally attached to the patella and distally to a cylindrical bone block (20 x 8.4 mm), served as graft. Tibial fixation in group A (n = 10) was done using a titanium interference screw (20 x 8 mm), in group B (n = 10) using a titanium staple, in group C (n = 12) using suture fixation over a bone bridge, and in group D (n = 14) using the press-fit fixation described above. In a materials testing machine, all specimens were subjected to continuously increasing load until failure at a velocity of 1 mm/second. Ultimate failure load, stiffness, stress-strain characteristics, and failure mode were evaluated.

RESULTS

Ultimate load to failure was 572 N (range, 473 to 680 N) in group A, corresponding to a fixation stiffness of 17.68 N/mm. For group B, ultimate load to failure was 608.4 N (range, 511 to 727 N) and stiffness of 19.92 N/mm. Bone block dislocation was the failure mode in groups A and B. Group C with exclusive suture fixation showed an ultimate load to failure of 304.5 N (range, 120 to 327 N) and a stiffness of only 6.96 N/mm. The mode of failure was suture cutout caused by the bone block in 9 of the cases and untying of the suture knot in 3 cases. Group D with press-fit fixation showed a significantly higher primary stability of 758 N (range, 513 to 993 N) relative to group C, with a corresponding stiffness of 25.12 N/mm (P <.02). In this group, the mode of failure was ligamentous rupture from the bone block. Regarding mechanical properties, no significant differences were seen between groups A, B, and D.

CONCLUSIONS

Tibial press-fit fixation allows for metal-free fixation with high primary stability. By refilling the bone tunnel, the ligament (with a rather small cross-sectional diameter compared with hamstrings) is safely fixed within the bone tunnel to prevent potential postoperative tunnel enlargement due to movement of the graft within the tunnel. Anchoring the graft at the entrance into the joint, it provides for reduced graft length and adequate elasticity and accomplishes the requirements of fixation at the correct anatomic insertion site.

Arthroscopic transglenoid suture repair for initial anterior shoulder dislocation

PURPOSE

To evaluate the long-term results after arthroscopic transglenoid suture repair for initial anterior shoulder dislocation. TYPE OF SYUDY: Outcome study.

MATERIALS AND METHODS

Selection for surgery was based on the sporting ambitions of the patients and the documentation of instability. Evidence of instability included the sonographic documentation of ventral drawer compared with the unaffected opposite shoulder as well as instability testing under anesthesia. Patients with preoperatively stable shoulder or multidirectional instability underwent conservative therapy. All patients underwent surgical repair with a transglenoid suture technique, initially using a single drill hole; in recent years, however, we have used 2 drill holes placed in the 3 o'clock and 5 o'clock positions. Postoperative care was initiated with 4-week immobilization in a Gilchrist bandage. Subsequently, physiotherapeutic mobilization was started, avoiding rotational movements for the first 3 weeks. In the period between 1988 and 1995, 72 patients with traumatic first-time dislocation underwent arthroscopic stabilization at the Department of Trauma Surgery of the Krankenhaus der Barmherzigen Brüder Eisenstadt. The patients included 61 men and 11 women with an average age of 27.2 years (range, 19 to 39 years).

RESULTS

The clinical instability documented showed a significant correlation to the instability found under anesthesia that was documented immediately before arthroscopic exploration. Arthroscopic exploration revealed a Bankart lesion in 25 cases (34.7%), with a small bone fragment found in 6 of these cases. Forty-three patients showed an avulsion of the capsulolabral complex displaced medially to the neck of the scapula, combined with a bucket-handle lesion of the superior anteroposterior labrum in 12 of these cases. Sixty-seven patients (93%) were available for clinical follow-up after an median of 66 months (range, 24 to 108 months) with patients achieving an average 91.3 points in the Carter-Rowe score. Five of the patients (6.9%) (average age, 20.4 years) experienced postoperative redislocation after 3 to 11 months being the result of an adequate trauma in 2 of the patients. All patients with redislocation had originally presented with a Bankart lesion, with medially displaced capsulolabral complex combined with a bucket-handle lesion of the proximal labrum in 2 patients. Eighty-five percent of the patients have resumed full sporting activity and presently have full load-bearing capacity of the operated shoulder.

CONCLUSIONS

Compared with the poor results after conservative therapy with recurrence rates of up to 90% for young, athletically active patients, arthroscopic treatment has been shown to be highly efficient.

Refilling of removal defects: impact on extensor mechanism complaints after use of a bone-tendon-bone graft for anterior cruciate ligament reconstruction

In a prospective study, the impact of refilling removal defects at the tibial tuberosity and patella on extensor mechanism complaints was studied after anterior cruciate ligament reconstruction with a bone-tendon-bone ligament graft. A conventional cannulated drill was sued in patients of group 1 (n = 62), and an oscillating hollow saw was used in group 2 (n = 70) for drilling and removing bone material from the tibial tunnel. On completing the procedure in the patients in group 2, the bone material removed was inserted into the bony removal defects at the tibial tuberosity and the patella. In both groups, the extensor mechanism was closed using loose sutures. Both groups underwent the same postoperative therapy regimen. All patients underwent clinical and radiographic follow-up after approximately 34 months. In this follow-up, no differences with regard to knee function as assessed by the IKDC rating scale and KT-1000 measurements were found between the 2 groups. The rate of mild to severe patellofemoral complaints was 31% (41 patients). Complaints related to the removal defects as assessed by kneeling and squatting on the operated knee were described by 25 patients (18.9%). No significant difference between the groups with and without refilling of the removal defects was observed, and the overall subjective ratings on a visual analog scale (VAS) (0 = no pain, 10 = severe pain) for kneeling and squatting were 5.57 and 3.69, respectively. Follow-up time was identified as the critical parameter for problems related to the extensor mechanism, such as complaints in kneeling and squatting, with hardly any problems observed after 2 years. On the other hand, anterior knee pain correlated significantly with the residual limitation of motion.

Arthroscopic anterior cruciate ligament reconstruction using a patellar tendon graft in press-fit technique: surgical technique and follow-up

A modified endoscopic technique for anterior cruciate ligament (ACL) reconstruction using an autologous patellar tendon graft is described using the early results for 120 patients. A special technique using an oscillating hollow saw allows for the rapid and standardized harvest of cylindrical bone plugs, ensuring safe and adequate femoral press-fit fixation. The complications encountered included one fracture of a bone back on plugging in as well as two cases with revision procedures for interference screw fixation due to insufficient femoral anchorage. Within the framework of a prospective study, all 120 patients underwent a control arthroscopy after the first postoperative year showing viable and mechanically stable grafts in 64 (53.3%) of the patients. In 44 patients (36.7%), viable though somewhat lax grafts were found, whereas the remaining 12 patients (10%) only showed insufficient tissue residues. All of these cases were the result of a ventral misplacement of the femoral insertion site representing the primary complication of transtibial technique. The results of the control arthroscopies showed a highly significant correlation with the clinical results for the IKDC score obtained in a follow-up after an average 29 (18 to 36) months. The results for stability according to the IKDC rating scale showed a normal or near-normal knee function in 76.7%. With regard to the subjective results in the IKDC rating scale, 83.3% of the patients (n = 100) assessed their knee function as normal or almost normal. The location and positioning of the femoral and tibial tunnel were evaluated in an exact radiographic evaluation showing an "ideal position" of the graft in only 94 cases (78.3%). Statistically, a significant correlation of stability with the femoral fixation site could be shown.

[Long-term results of arthroscopic implantation of a Trevira prosthesis for replacement of the anterior cruciate ligament]

The present report describes the results of long-term follow-up after arthroscopic replacement of the anterior cruciate ligament with a synthetic ligament made of "Trevira-Hochfest". Over a period of 27 months 88 Trevira ligaments were implanted at the Department for Trauma Surgery of the Krankenhaus der Barmherzigen Brüder in Eisenstadt using the arthroscopic assisted two-drill-hole technique. The overall complication rate found after follow-up for up to seven years was 47.7% (42/88). In 14 patients ligament ruptures occurred within the first 24 months after surgery; a further 8 ruptures were seen in the subsequent years. Including the 12 instable knee joints found at the time of the follow-up, the overall rupture rate seen was 38.6% (34/88). In obvious contrast to reports on comparable synthetic ligaments, the ruptures seen invariably showed smooth rupture surfaces without any fraying. In all of the cases removal of the ruptured ligaments was possible without any problems. It is highly likely that this material-specific characteristic is also responsible for the comparably low incidence of synovitis (18%) with only one of our patients requiring an explantation of the synthetic ligament due to recurrent synovitis. Of the patients with intact Trevira ligaments excellent or good results in the OAK-Score were seen for 76.8% at follow-up after up to seven years. Follow-up stability tests performed in 69 patients showed intact Trevira-ligaments in 57 cases (82.6%). The radiographic findings obtained for the postoperative follow-up for up to seven years failed to show any clinical evidence of the arthrosis-promoting effects of foreign-body synovitis demonstrated in experimental models.

[Long-term results of surgical management of patellar fractures. Conservative versus resection procedures]

In a retrospective analysis of 70 patellar fractures the-long-term results after surgery were followed-up for periods of up to twelve years. Subjectively, excellent or satisfactory results were reported by 89% (n = 62) of patients. Clinical evaluation in the Lysholm score showed excellent or good results in 74.2% (n = 52) of cases. The results in the Lysholm score correlated well with the radiological evidence of arthrosis (p < 0.014) and with the clinical signs of chondropathy (p < 0.0005). Poor results (79.2 Lysholm points) were seen for comminuted fractures; however, the results for patients with distal transverse fractures were even lower (68.28 Lysholm points). Medial transverse fractures as well as distal patella pole ruptures were shown to have good prognostic results. In cases with comminuted fractures resection techniques are to be preferred to conservative procedures (p < 0.015). As regards long-term results in our patient population, partial patellectomy showed no obvious advantages over total patellectomy. In cases with multi-fragment fractures with questionable possibilities for reduction, cases with extensive cartilage damage as well as cases with distal transverse fractures partial or full patellectomy is recommended as the therapy of choice.

[Long-term results of arthroscopic meniscectomy]

The long-term results after partial arthroscopic meniscectomy were evaluated in follow-up examinations on 77 patients performed according to identical criteria after post-operative periods of two (6-36 months) and seven years (66-96 months). The subjective results after up to more than seven years showed a stable course and were unrelated to the radiological signs of osteoarthritis. The objective clinical results, assessed in the Lysholm score, showed a significant deterioration as compared to the two-year follow-up (p < 0.0002). In particular, an obvious increase of pain and an increased tendency for swelling were observed, while the results in the Lachman test showed a significant reduction of anterior instability (p < 0.0015) as an obvious result of a marked improvement of muscle strength. These results also correlated with a significant increase of sporting and exercise capacity as compared to the results obtained in the two-year follow-up. While osteoarthritis rates seen in the first follow-up were similar to the preoperative findings, a massive increase of osteoarthritis could be seen at the second follow-up after a further five years with only 22 of 77 patients (28.6%) showing no radiographic signs of osteoarthritis. In 31 patients (40.25%) with negative preoperative findings slight to moderate signs of osteoarthritis were seen in the seven-year follow-up. Regardless of the type of meniscal tear the osteoarthritic changes seen were related to the age of the patient and the stability of the joint and were significantly different from those in the non-operated, contralateral joint.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of arthroscopic ventral limbus capsule refixation after primary traumatic shoulder dislocation]

The three-year results for arthroscopic refixation of the labrum-ligament-capsule complex after traumatic primary dislocation of the shoulder will be discussed. This prospective study included only patients with primary dislocations showing radiographic signs of anterior instability in the drawer test and no accompanying bony injuries. Twenty-six patients with an average age of 31 years and arthroscopic suture had been dismissed from postoperative treatment after an average 15 weeks showing a fully mobile and pain-free shoulder joint. At the time of follow-up the average results obtained with our own score were 94.1 points. 61.5% of the patients showed fully mobile shoulder joints and 84.6% reported full sporting capacity. Negative findings were obtained for all stability tests performed after 32 months. No recurrencies had occurred until the time of the follow-up. Compared to the reluxation rates described in the literature for traumatic primary shoulder dislocations in juvenile patients, our three-year results were highly positive and we will continue to use arthroscopy in the treatment of instable shoulder joints after traumatic primary dislocation in order to avoid recurrencies and associated sequelae.

[Foreign body synovitis--a limiting factor in use of the Trevira ligament in cruciate ligament surgery?]

In a prospective clinical study on 32 patients with Trevira ligament implants arthroscopic and histological findings were used to assess the articular effects of the synthetic ligament. In group 1 of patients with intact Trevira ligament no changes associated with foreign-body reactions were seen. In group 2 with abrased or frayed synthetic ligaments generalised foreign-body reactions in the suprapatellar recess as well as perivascular, round-cell infiltrates were seen in four out of six patients; four of the six cases also showed fibrotic signs indicative of prearthrotic changes. In group 3 with ruptured Trevira ligament no diffuse foreign-body reactions in the suprapatellar recess were seen in any of the 16 cases. In the intercondylar space foreign-body reactions correlating with the age of the implant were identified (p < 0.03). In 18% of cases with ruptured Trevira ligament generalised foreign-body reactions were seen; however, these changes were not accompanied by chronic inflammatory changes. Cases with technical shortcomings associated with a gradual fraying of the synthetic ligament invariably showed diffuse foreign-body reactions as well as chronic inflammatory infiltrates. In patients with spontaneous ligament rupture due to repeated trauma foreign-body reactions were restricted to the intercondylar space. In spite of the histological evidence of foreign-body granuloma no permanent clinical articular effects could be seen in our patients population within the follow-up time of up to 60 months.

[Long-term results of surgical management of tibial head fractures]

In a follow-up of an overall 100 cases with proximal, intraarticular tibial fractures the long-term results after surgical treatment were evaluated in a critical analysis over periods of up to 12 years. The rate of postoperative complications as regards wound healing deficiencies and infections was 6% and thus consistent with the complication rates reported in literature. While most cases showed good radiographic postoperative results, poor clinical results in the Lysholm score were seen with 29% of cases at the time of the follow-up. The clinical results showed a highly significant correlation with the type of fracture (p < 0.001). As regards the radiographic long-term results, minor to severe arthrotic changes were seen in 71% of cases. These changes also showed a significant correlation with the type of fracture--as graded by the principles of the AO group. Impressions or formation of overlappings of the affected joint surfaces of up to 5 mm were seen in nearly 50% of cases, while in a further 13% the extent was up to 10mm. These findings correlated well with the complaints about pain on the part of the patients and with the type of primary fracture. The objective of surgical treatment is to provide for an exercise-stable osteosynthesis in order to restore early function of the affected joint. The essential criterion is the extent of soft tissue damage determining the type and the timing of treatment. Arthrosis due to the primary damage of cartilage tissue is to be expected even with sufficient primary surgical management.

Physiopathology of the knee joint after distal iliotibial band transfer

In an experimental study of 14 cadaver knee joints, the pressure load on the joint surface after distal iliotibial band transfer was measured using Fuji Prescale foils. With an intact anterior cruciate ligament, increases of up to 153% for the average pressure load and of 225% for the total pressure in the lateral compartment were found in relation to the fixation point chosen. At point P3--slightly dorsal to the insertion of the lateral collateral ligament--the area loaded with maximum pressure increased to six-fold. Fixation at the transition of the lateral femoral condyle to the femoral shaft at the start of the linea aspera was associated with the least pressure increases in both the lateral and the medial compartments. Under all experimental conditions, lateral extra-articular stabilization with fixation at the insertion of the fibular collateral ligament was shown to be associated with significantly higher load increases. While a shift of pressure load to the dorsal third was seen in the lateral compartment, the mid-third remained the focus of the pressure load in the medial compartment. After transection of the anterior cruciate ligament and iliotibial band transfer at the "over-the-top" point, a significant shift of pressure towards the medial compartment was seen, while the lateral pressure load decreased. Medially, the area loaded with peak pressure remained constant, while the corresponding area in the lateral joint space showed a highly significant decrease to nearly one-third of normal. After additional bilateral meniscectomy this tendency was even more pronounced.(ABSTRACT TRUNCATED AT 250 WORDS)

[The value of arthroscopy in the management of anteromedial lesions of the knee joint. A therapy concept]

Based on the clinical findings from twenty-seven patients over a mean follow-up period of 27 months, a therapeutic management plan for anteromedial lesions of the knee is presented. This is based both on the usual instability tests in narcosis and on accurate arthroscopic evaluation of the lesion to the medial ligamentous apparatus. Additional open reconstruction of the posteromedial ligamentous apparatus was only performed in cases of arthroscopic lesions Type III after arthroscopic management of all internal knee-joint injuries. The average period of rehabilitation was 10 weeks in the case of Type I lesions and 16 weeks in the case of Type III lesions. This compares with results following conservative treatment. At follow-up, 66% of the knee-joints were found to be stable in the Lachman test, and 81.5% were stable in the abduction stress test. Excellent and good results were achieved in 96.2% of cases according to the Lysholm scoring scale. The advantages of arthroscopy lie not only in the possibility of treating all internal knee-joint injuries including the deeper layers of the medial ligamentous apparatus, but also in protecting the vastus medialis, which is of particular importance for the prognosis of anteromedial lesions.

[Indications for surgery in distal radius fractures]

In this retrospective study, the results of conservative treatment of 406 fractures of the distal radius are analysed and the limitations of conservative therapy indicated. In all, 107 male patients (average age 45 years) and 299 women (average age 65 years) were examined. In only one-third of these cases were both radiographically and clinically. Of the primarily dislocated fractures, 19% healed in the correct anatomical position with satisfactory to good clinical results. Up to now, treatment of fractures of the distal radius with dorsal tilting has been regarded as a form of conservative therapy. Although certain types of fracture, in particular unstable ones, have always been regarded as cases for operative treatment, no attempt has ever been made to define the limits between conservative and operative treatment. Evaluation of the results clearly indicates that the classification according to Frykman, the one most commonly in use, cannot be used as a primary criterion for operative treatment. In the course of a meticulous statistical evaluation, we defined the radiological parameters precisely with reference to shortening, dorsal tilt and instability and drew up a classification to define the primary indications for operation in cases of fracture of the distal radius. Shortening by over 3mm, dorsal tilting by over 10 degrees, presence of a dorsal debris zone, rupture, or osseous avulsion of the radioulnar syndesmosis as a further instability factor show the limits of conservative therapy and are clear indications for operative treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results after surgical stabilization of the ruptured shoulder joint. Combination procedure versus Bosworth screw]

From 1979 to 1989, 46 patients were operated on for luxation of the acromioclavicular joint (Tossy III) in the department of trauma surgery of the Krankenhaus der Barmherzigen Brüder, Eisenstadt. During the first few years, a combination of traction strapping and Boswoth screws was applied (22 patients) Owing to the high incidence of joint trauma and resulting functional deficit, this procedure was abandoned in favour of fixation with the Bosworth screw alone, combined with transosseous refixation of the joint capsule. The incidence of postoperative complications was approximately equal for both procedures (a total of 3 infections which healed completely, 7 secondary dislocations on removal of the screws, 5 cases of broken or migratory screws). Radiological and clinical follow-up examinations were performed on 36 out of 46 patients up to 93 months postoperatively. In 14 cases, the radiological examination revealed moderate to pronounced signs of arthrosis; the combined procedure was followed by a significantly higher rate of arthrosis. A significant correlation was also found between residual displacement and the occurrence of arthrosis. In cases where only Bosworth screws were used, more joint diastases occurred. In the opinion of the authors, unsatisfactory results are likely to be due to faulty operational technique rather than to the method itself. In general, better reductional results were achieved with the combined method. With reference to the restoration of joint function, however, significantly better results were achieved with exclusively extra-articular stabilization.

[Avulsion fractures of the knee and upper ankle joint. Classification and therapy]

Injuries of the joint surface interfere with joint mechanics. Avulsed fragments should be reattached to prevent development of arthrosis. Of 150 fractures of the knee joint 72% were osteochondral and 28% chondral avulsion. About half of the chondral lesions could be refixed successfully. If replantation is impossible, this cartilage defect has to be smoothed and, when indicated, connected to spongy bone by subchondral drilling.

[Treatment of open tibial fracture with fixateur externe]

External fixation with a Hoffmann or an ASIF frame was used in the treatment of 50 severe open lower leg fractures from 1979 to 1987. In 7 cases consolidation was achieved by means of external fixation without changing to any other method. Plaster cast fixation was subsequently performed after soft-tissue healing in 35 patients. Further methods of treatment applied after external fixation were intramedullary nailing in 5 cases, internal stabilization with a plate in 1 case and provision of a surgical support in 1 case. In 1 patient early amputation was necessary. On average, fracture healing took 6.7 (4-15) months, significantly correlating with the severity of soft-tissue lesion. Compound fractures of the proximal tibial shaft turned out to be problem cases, requiring up to 15 months for bone union. Acute infections occurred in 6 cases (12%), despite primary antibiotic prophylaxis. Nonunion was noted in 2 patients. A follow-up examination of 33 patients after a median of 45 months (range 6-99) showed full weight-bearing in all cases. Persistent soft-tissue problems were found in 7 patients, chronic osteitis in 4, and shortening of the extremity by up to 2 cm in 11 cases. One-third of the patients were out of work or had had to change their jobs as a social effect of their severe injuries.

[Therapy and prognosis of medial ligament injury of the knee joint]

We tried to classify the potential lesions of the medial ligament of the knee joint with regard to the therapeutic and prognostic background elements. We analyzed 354 lesions of the medial ligament and report the therapeutic alternatives. In addition, we made an attempt to correlate some of the lesion forms and their locations with the sport causing the injury.

[Chronic fibular ligament insufficiency at the upper ankle joint. Late results after modified Watson-Jones plastic surgery]

The findings at clinical and roentgenological follow-up examination of 44 patients are reported to illustrate the long-term results of a modified Watson-Jones technique up to 90 months after the operation. The clinical results (86.3% of the patients without complaints and 88.6% with subjective stability of the ligaments) correspond with those given by a variety of sources in the literature. The roentgenological examination, on the other hand, showed signs of grade I or II arthrosis (Bargon scale) in 61.3% of cases, and arthrosis was worse than before the operation in nearly all cases. The patients in the group, that had received more conservative treatment with an average 6.3 years between lesion and surgical treatment (group 1), had the highest incidence of arthrosis, with 73.6%. In 10 cases the clinical examination revealed reduced supination and dorsiflexion attributable to the tenodesis effect associated with the Watson-Jones technique. In view of the high rate of arthrosis, younger patients and patients with a short tendon part of the peroneus brevis muscle should be treated by another, more "physiological" method.

[A new technic for arthroscopic reinsertion and augmentation of the recently torn anterior cruciate ligament]

The arthroscopic examination of every recent haemarthrosis of the knee, even in cases without clinically obvious instability has increased the number of primary diagnosed ruptures of the LCA in the last years. The most frequent lesion of the LCA was the proximal rupture. The usual methods for the operative treatment of the ruptured LCA require the opening of the knee joint and cause the weakening of hamstrings, with all disadvantages connected with these procedures. Basing on the experiences in arthroscopic surgery of meniscal lesions and the good results of alloplastic augmentation an new method of arthroscopic refixation and augmentation of the torn LCA has been developed. The use of an arthroscopic meniscal stitcher enables anatomically exact reconstruction of the torn ligament through a femoral tunnel. Augmentation by an LAD-band (Kennedy) or Trevira band (Hoechst) allows postoperative functional treatment, avoiding atrophic degeneration of muscles and loss of mobility by immobilisation. Postoperative pain is reduced to a minimum compared to conventional technics. The period of rehabilitation is considerably shortened.