[Ultrasonographic imaging of pneumarthrosis of the knee joint--case report and experimental cadaver study]. / Sonographischer Nachweis von Luft im Kniegelenk - eine experimentelle Studie und klinischer Fallbericht.

In case of penetrating injuries near to the knee joint showing only a small skin lesion and no damage to tendons and neuro-vascular structures, opening of the joint cavity has to be taken into consideration. Besides surgical revision of the penetration canal, radiological depiction of free intraarticular air may be useful. We report the cases of two patients, who suffered from intraarticular effusion and pain two, respectively three days after a penetrating injury. In both of them, free intraarticular air in the suprapatellar region could be depicted by ultrasonographic assessment. Subsequent evaluation of radiographs showed intraarticular air already being there at the day of admittance. Performing an experimental study in fifteen cadaver knee joint specimens, the reliability of this technique was evaluated and documented. Using an injection needle, air was insufflated into the knee joints with or without previous instillation of fluid. Afterwards sonographic assessment was performed using 7,5 - 13 MHz linear probes and Siemens (Elegra) equipment. Ultrasonographic detection of pneumarthrosis of the knee joint was possible early and reliably in both of the patients reported. With sufficient experience of the clinician and adequate equipment, even singular intraarticular air blisters are detectable, especially in cases of concomitant intraarticular effusion. By ultrasound it was possible to detect pneumarthrosis with at least 0,5 ml, by X-ray with at least 2 ml. Ultrasonography proved to be a reliable diagnostic tool for the detection of free intraarticular air within the knee joint. This fact should be considered in the differential diagnosis of unclear knee joint disorders after penetrating injuries.

A new bioabsorbable interference screw: preliminary results of a prospective, multicenter, randomized clinical trial.

SUMMARY: A randomized clinical trial was conducted to compare a bioabsorbable polyglyconate screw (Endo-Fix; Smith & Nephew, Andover, MA) to a metal screw in anterior cruciate ligament reconstruction. A total of 124 patients were operated on and 113 assessed up to 1 year postoperatively. Assessments included a history and physical examination, the IKDC evaluation, and knee arthrometry measurements. No significant differences were found between the groups with respect to any of the IKDC problem areas at 1 year. The IKDC final evaluation was normal or nearly normal in 92% of polyglyconate patients and 90% of controls. The incidence of postoperative complications was similar in the 2 groups. One polyglyconate patient developed a subcutaneous cyst that may have been related to breakdown of the screw. This resolved without treatment and the patient had an excellent clinical outcome. This study shows that the polyglyconate screw is an effective alternative to metal in endoscopic reconstruction of the ACL.

Failure of clinical methods in assessing graft integrity after anterior cruciate ligament reconstruction: an arthroscopic evaluation.

We reviewed the findings of 24 patients who underwent knee arthroscopy following a bone-patellar tendon-bone autograft anterior cruciate ligament (ACL) reconstruction. Preoperative symptoms included pain, swelling, catching, and/or locking. Only one patient presented with subjective instability. The subjective and objective clinical findings as well as KT-1000 examination were compared with the arthroscopic findings. Thirteen of the 24 patients had an insufficient ACL graft by arthroscopic examination. In only 5 of these patients did the physical examination and/or KT-1000 results reliably detect an insufficient ACL graft. The remaining 8 patients had a stable knee by subjective and objective clinical criteria as well as strict KT-1000 criteria. No significant degenerative changes or lack of motion was present in this group. Also, 7 of the 8 patients had an excellent or good Orthopädische Arbeitsgruppe Knie (OAK) score and maintained a high level of function. In the two patients who underwent preoperative magnetic resonance imaging the lack of an intact graft was confirmed. A subset of patients appear to have stable knees despite the lack of a functioning ACL graft. Therefore, standard clinical and KT-1000 criteria for ACL deficient knees have limitations in detecting graft integrity after ACL reconstruction. Arthroscopy or magnetic resonance imaging may be needed when graft integrity is in question.

Transsection of the peroneal nerve complicating knee arthroscopy: case report and cadaver study.

We report the case of a 36-year-old male patient who sustained a hyperextension trauma of the left knee. After performing diagnostic arthroscopy (partial tear of the anterior cruciate ligament) and partial resection of the anterior cruciate ligament, the patient experienced a complete paralysis of the peroneal nerve. One year after the first surgical procedure, a reconstructive repair of the peroneal nerve and a transfer of the anterior tibial muscle was performed. This complication is reported for the first time in literature.

[Are complications in cruciate ligament replacement operations with patellar tendon transplantation dependent on surgical technique and surgical timing?]. / Sind Komplikationen bei Kreuzbandersatzoperationen mit Patellarsehnentransplantat von OP-Technik und OP-Zeitpunkt abhängig?

HYPOTHESIS: In a retrospective study we analyzed our results of ACL reconstructions with a patellar tendon graft. We wanted to know if the complications were dependent upon timing and technique of surgery. METHOD: We reviewed 283 patients after ACL-reconstruction, who underwent an operation with bone patellar tendon graft between 1984-1993. In our study we particularly looked for complications. The overall rate of complications was 21.6% dependent on the applied technique. Infections, DVTs, limitations of movement and graft failures were the most common complications. Furthermore we analyzed the timing of operation. Arthrofribrosis was less common in the group with delayed reconstruction (6.1%) whereas in the primary reconstruction group the rate was 17.6%. For this reason we changed our management with regard to the timing of operation. Meniscal injuries were the most common additional injuries in both groups. Conservatively treated ACL-ruptures showed a high rate of mensical ruptures in combination with cartilage injuries. CONCLUSION: Because of these results we put more emphasis on patient information to achieve the optimal result and to meet the individual needs for every patient.

[Ultrasound imaging of osteosynthesis materials in traumatology--an experimental study]. / Sonographische Darstellung von Osteosynthesematerial in der Traumatologie--eine experimentelle Studie.

The aim of the present study was to establish the typical ultrasound (US) patterns of metal implants used for internal fracture fixation, and consequently to use US for the identification and localisation of such implants. We investigated both the visualization of the implants in term of size and shape, material (titanium, steel, biodegradable screws) and surface structures, and possible changes in the echo pattern in relationship to surrounding structures (muscles, body fluid), proximity to bone, and changes in the angle of insonation. For this purpose ultrasonography was performed on artificial and isolated cadaver bones in a water bath, as well as on cadaver limbs following prior implantation of screws, plates, K-wires and cerclage wires. We found that, from a certain size upwards, metal implants can be easily localised on the basis of typical artefacts (resonance artefact, comet-tail artefact). US is thus most suitable for localisation of metal implants. The spatial and anatomical relationship to bony structures, joints, tendons, muscles and blood vessels can be determined with a high degree of accuracy.

[Complications in 283 cruciate ligament replacement operations with free patellar tendon transplantation. Modification by surgical technique and surgery timing]. / Komplikationen bei 283 Kreuzbandersatzoperationen mit freiem Patellarsehnentransplantat. Beeinflussung durch Operationstechnik und Operationszeitpunkt.

In our retrospective study we reviewed 283 patients who were operated on between 1984 and 1993 after an ACL-rupture. We used a free patellar tendon bone graft in all patients. The aim was to assess the complications such as infections, thrombosis, limitation of movement and graft failures. We also looked on the timing of operation and the technique. We saw an overall complication rate of 21.6%. The most common complication was a restricted range of motion in 10.9% which required surgery. In patients treated immediately after injury (within 7 days) we found an arthrofibrosis rate of 17.6%. In delayed surgery (more than 4 weeks after injury) this complication was only seen in 6.1%. The rate of infection was 4.6%, the rate of thrombosis 1.8% and in 4,2% we had to accept an ongoing instability. With these findings we now evaluate the needs and the social environment even more closely to find the best treatment protocol for each individual. In conclusion we favour secondary ACL-reconstruction.

Quantitative assessment of fracture healing. The value of computerised sonometry in a correlative animal experiment in sheep.

Usually follow-up of the healing process of bone fractures is by subjective assessment of standard X-rays, based on the clinician's personal experience. It is therefore impossible to completely avoid misjudgements in the evaluation of the mechanical stability. Other authors have reported that the mechanical response of bony structures to a knock impulse allows a definitive statement about the stiffness of a fracture. The practicability of computerised sonometry in computer-aided evaluation of the mechanical vibration reaction and the acoustic transmission of sound through osseous structures for assessing stability has been proved in experimental and clinical studies. We designed an animal study that would allow a systematic correlation between the diagnostic investigations in general use. As a main goal, this study tries to correlate sonography with other quantitative techniques, even if they are not used under everyday clinical conditions. Our results show that methods based on direct assessment of the mechanical stability between fracture fragments allow a more exact evaluation of fracture healing. This study helps to classify the results of computerised sonometry together with other diagnostic procedures used for the evaluation of fracture healing, and furthermore provides a basis for clinical interpretation of the findings of a new, non-invasive technique for precise quantitative assessment of fracture healing.

Arthroscopic treatment of meniscal cysts.

In a series of 1160 arthroscopies we found 16 meniscal cysts; 12 involved the lateral joint line and two the medial, and two were intra-articular. In all but two cases, arthroscopy showed meniscal tears. We recommend arthroscopy of all cases to correct the meniscal lesion, and to evacuate the cyst into the joint by opening the joint capsule. This was successful in 12 cases, with no recurrence after an average follow-up of 18 months. Only two patients with no meniscal lesion on arthroscopy required an additional external incision for cyst removal.

[Blood supply to the cervical spinal cord and possible therapeutic consequences in cervical spinal cord injuries]. / Die Blutversorgung des zervikalen Rückenmarks und mögliche therapeutische Konsequenzen bei zervikalen Rückenmarkverletzungen.

The study was designed to demonstrate the blood supply to the cervical cord through radicular branches and was carried out in 23 human cadavers into which preparations were injected by the intra-articular route. One corrosion cast of the head and neck showed extravertebral anastomotic pathways. After removal of the vertebral bodies and discs from C1 to D3, the anterior spinal artery and radicular branches were identified and dissected back to their origins from the vertebral, deep or ascending cervical arteries. Twelve preparations had only one or two radicular branches reaching the cervical spinal cord. If there is traumatic compression of an ascending branch a high risk of ischaemic damage to cranial areas of the spinal cord arises. The blood supply to the cervical enlargement of the spinal cord was provided by branches of the deep cervical artery in eight preparations, but only in one by branches of the vertebral artery. We therefore plead for decompression of the anterior spinal artery and the spinal cord and for sufficient arterial blood pressure, and give our reason for these demands.

In vivo monitoring of circulation in the intact anterior cruciate ligament using the laser Doppler flowmeter.

Laser Doppler flowmetry permits observation of circulation in the microcapillary regions of structures under in vivo conditions. We used a laser device manufactured by the Swedish company Perimed and a special probe to observe the capillary circulation in the anterior cruciate ligament during arthroscopic surgery. This produces measured values in millivolts; these values are relative in nature and cannot be used to determine an absolute value for capillary circulation by volume per unit time. Under standardized conditions, circulation measurements and simultaneous recordings with a two-channel recorder were made from 11 patients. In all cases, pulsations of the capillary circulation synchronous with the heart beat could be seen on three measuring points on the anterior cruciate ligament; these disappeared upon complete deprivation of blood supply. We found a large individual range of variation in the so-called blood cell flux values from 30 to 620 mV. The magnitude of the heart-synchronous pulsations ranged between 20 and 240 mV. Only vague linear relationships were found (a) between the individual measuring points and (b) between the flux values and the magnitude of pulsation; there was no relationship between the flux values and blood pressure and/or red blood count (erythrocyte count, hemoglobin, hematocrit).

[The value of magnetic resonance tomography in diagnosis and follow-up of cervical spine injuries]. / Stellenwert der Magnetresonanztomographie (MRT) in der Diagnostik und Verlaufskontrolle von Halswirbelsäulenverletzungen.

We report upon 12 cases of magnetic resonance imaging of cervical spinal cord injuries, in 8 cases done within 24 h after the injury. We found haemorrhages in the spinal cord in 3 cases, compression of the spinal cord in 3, swelling of the spinal cord in 2, and transsection of the spinal cord and hematoma in the epidural space in 1 case each. A normal MR image was seen in a patient with a complete transverse lesion of the spinal cord. The other 4 MR examinations were carried out between 2 weeks and 8 months after injury or operation. In 2 of these trauma victims interbody fusion of the cervical spine was performed, and the neurological deficit was subsequently worse in both. In 1 patient the course of a haemorrhage within the spinal cord was monitored by MR imaging: 1 image revealed the treatment of a burst fracture of C-7 with an interposed flap from the greater omentum.

[Arthroscopic technique for replacing the anterior cruciate ligament using a free patellar tendon transplant]. / Arthroskopische Technik zum Ersatz des vorderen Kreuzbandes mittels freiem Patellasehnentransplantat.

The replacement of the anterior cruciate ligament (ACL) by a free patellar tendon graft is a well-known procedure. The disadvantage is that the necessary arthrotomy destroys the nerve supply of the joint capsule. Therefore, we developed a procedure of ACL replacement that can be done by arthroscopy without opening the joint except for a small incision needed for the arthroscopy and working canal. The surgical technique is described.

[Radiologic diagnosis of cervical spine injuries]. / Radiologische Diagnostik der Halswirbelsäulenverletzungen.

This investigation was designed to evaluate the radiological methods used for diagnosis of cervical spine injuries. In the time from 1977 to 1990, a total of 102 patients with 113 fractures or fracture-dislocations of several segments of the cervical spine were diagnosed and treated in the University Surgical Clinic in Graz; 36 of these patients had lesions of the upper cervical spine and 66, lesions of the lower cervical spine. All trauma patients with disturbances of consciousness or neck discomfort reported on questioning or elicited by palpation underwent three-view radiographic screening for cervical spine injuries (lateral, AP and open-mouth views). This led us to suspect cervical spine injuries in all 102 patients. Computerized tomography was performed in 76 cases, which yielded additional information in 55 cases about the middle and posterior column and the adjacent vertebral bodies. In 13 cases conventional tomograms were important to confirm the diagnosis of dens fracture. Except for the diagnosis of hanged-man and dens fractures, computerized tomography is accepted as the second step for the evaluation of cervical spine injuries. We performed 8 investigations with magnetic resonance imaging in 7 patients, and noted spinal cord lesions of low signal intensity in 3 of these cases.

[Heterotopic ossifications in a patient with severe craniocerebral trauma]. / Heterotope Ossifikationen bei einem Patienten mit schwerem Schädel-Hirn-Trauma.

Patients with severe head injury and fractures of joints or of long bones often show a hypertrophic callus formation which leads to a rapid consolidation of a fracture but can also lead to an ankylosis of the joints. This is the retrospective report of a patient who showed this phenomenon.

Complications after an unusual procedure in the treatment of a cervical spine burst fracture. A case report.

A 21-year-old man sustained a burst fracture of the 7th cervical vertebral body complicated by a complete loss of sensory and motor functions. He was treated with a pedicled greater omentum flap interposed between the cervical and thoracic spine in a Latin American country. The purpose of this paper is to point out the atypical way of the initial mismanagement. By applying basic principles of fracture management, open reduction and internal fixation was performed resulting in spinal stability which should enhance any chance of recovery of the patient.

Interbody fusion of the lower cervical spine: a dangerous surgical method?

Our follow-up study of 175 cases of interbody fusion of the lower cervical spine was conducted to show the complications that occurred in our department with what is considered to be a tried and tested method. From 1976 to 1990, 175 patients were treated with this method. These 175 cases included 150 fractures and/or dislocations. The indications for surgery in the remaining 25 cases were tumors and metastases, inflammatory or degenerative diseases and chronic instabilities following laminectomy. The following complications were seen: 4 cases of infection, 3 postoperative redislocations, 2 cases of extensive loosening of metal, 1 unilateral lesion of the vertebral artery, 1 nonunion with plate fracture, 1 post-operative radicular disorder in an otherwise neurologically normal patients, and 1 secondary extension of the interbody fusion required after failure to recognize a two-segment lesion.

[External torsion fractures of the tibia combined with ankle joint fractures]. / Auswärtsdrehfrakturen des Unterschenkels kombiniert mit Sprunggelenksfrakturen.

The aim of this retrospective study is to emphasize on combined fractures of the tibia with lesions of the ankle joint. The report bases on 820 fractures of the lower leg. 123 cases showed external rotation fractures of the tibia, which were combined with lesions of the ankle joint in 88 cases. 25 patients were operated on the ankle joint. Because of the combination of external rotation fractures with lesions of the ankle joint, which accounted to 65% of the posterior tibial margin, to 17% of the lateral malleolus and to 3% of the syndesmosis, it is important to investigate the ankle joint radiologically and clinically.