Posteriorer Zugang zum Schultergelenk

Zusammenfassung : Operationsziel : Schonender Zugang zum posterioren Schultergelenkbereich. Indikationen : Posteriore Schulterstabilisation. Posteriorer Knochenaufbau/-spananlage des Glenoids. Korrekturosteotomie des Glenoids. Versorgung von Skapulahalsfrakturen. Versorgung von posterioren Glenoidrandfrakturen. Versorgung von Akromionfrakturen. Schulterarthrodese. Biopsien. Tumorentfernung. Relativ: Schulterendoprothese mit z.B. gleichzeitigem posterioren Glenoidaufbau. Relativ: Behandlung von Luxationsfrakturen des proximalen Humerus. Kontraindikationen : Allgemeine Kontraindikationen. Operationstechnik : In Seitenlagerung Aufsuchen der Landmarken: Spina scapulae und Akromion. Variabler Hautschnitt je nach zu versorgender Struktur: horizontal, über der Spina scapulae zentriert, bis schräg entlang der Margo lateralis scapulae, bis vertikal über dem Gelenk zentriert. Eigene Präferenz: Winkelhalbierende zwischen Spina scapulae und Margo lateralis scapulae. Von lateral (Subakromialraum) nach medial Ablösen des Musculus deltoideus mit einer kleinen Knochenschuppe von der Spina scapulae. Zum Glenoid: Eingehen zwischen Musculus infraspinatus (Nervus suprascapularis) und Musculus teres minor (Nervus axillaris). Zum Skapulahals (Achtung: Nervus axillaris identifizieren!): Eingehen zwischen Musculus teres minor (Nervus axillaris) und Musculus teres major (Nervus subscapularis) Falls eine Erweiterung des Zugangs erforderlich ist, ansatznahes Durchtrennen der Sehne des Musculus infraspinatus, welcher nach medial gehalten werden kann (cave: Nervus suprascapularis und Arteria circumflexa scapulae!). Weiterbehandlung : Entsprechend der zugrundeliegenden operierten Pathologie. Ergebnisse : Die Ergebnisse nach Operation über einen posterioren Zugang sind vor allem von der behandelten Pathologie abhängig. In der Klinik der Autoren wurden zwischen 1982 und 1995 24 Patienten (26 Schultern) mit posteriorer Instabilität durch einen offenen posteroinferioren Kaspelshift behandelt. Die durchschnittliche Nachuntersuchungszeit betrug 7,6 Jahre. Der alters- und geschlechtsadaptierte Constant- Murley-Score lag bei 91%. Subjektive Patientenbewertung: 24 Schultern gut bis sehr gut, zwei Schultern mäßig. Die Rezidivrate betrug 23% (alle Schultern waren voroperiert, oder es war ein erneutes, adäquates Trauma aufgetreten). Zugangskomplikationen (Schwäche oder Insuffizienz) wurden nicht beobachte

Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability

Background: Recurrent patellar instability is a common problem after dislocation. The medial patellofemoral ligament (MPFL) contributes 40-80% of the total medial restraining forces. This study assessed the clinical and radiological outcome after a follow-up of 4years after linear MPFL reconstruction using an ipsilateral Semitendinosus tendon autograft. Study design and methods: 15 knees in 12 patients were examined with a mean of 47months after linear reconstruction of the MPFL at a mean age of 30years. 3 knees underwent previous surgery. 3 patients had mild trochlear dysplasia grade I or II, according to the classification of Dejour. If preoperative tibial tuberosity-trochlear groove distance (TTTG) was more than 15mm, patients underwent additional medialisation of the tibial tuberosity (n=8) creating a similar postoperative situation for all patients. All patients were available for a postoperative evaluation, which consisted of a subjective questionnaire, the Kujala score, and the recording of potential patellar redislocation and apprehension. Patellar height and tilt was measured on plain radiographs. Postoperative CT scans were performed in patients with an additional tibial tuberosity-transfer. Results: Postoperatively, one patient reported on recurrent bilateral redislocation. Physical examination however revealed no findings. Three knees presented with persistent patellar apprehension. Thirteen knees had improved subjectively after surgery. The mean Kujala score improved significantly from 55.0 to 85.7 points. The patellar tilt decreased significantly from 11.3° to 9.2°. Four knees had patella alta preoperatively, but only two at the latest follow-up visit. Previous surgery or additional trochlear dysplasia had no influence on the clinical outcome. Conclusion: MPFL reconstruction improves clinical symptoms, reduces the patellar tilt substantially, and may correct patella alta. Additional mild trochlear dysplasia did not compromise the outcome; however, this fact needs further attention in a larger study grou

Therapie des femoroazetabulären Impingements über die chirurgische Hüftluxation: Technik und Ergebnisse

Zusammenfassung: Die chirurgische Hüftluxation ist eine sichere und etablierte Technik für die Behandlung des femoroazetabulären Impingements. Die Komplikationsrate ist niedrig und mit der korrekten Technik, welche die Blutversorgung respektiert, tritt eine Femurkopfnekrose nicht auf. Die häufigsten Komplikationen sind milde ektope Ossifkationen und die Trochanterpseudarthrose. Die intraartikuläre Chirurgie schließt sowohl die azetabuläre wie auch femorale Korrektur ein. Klinisch kann in ca. 75-80% der Fälle ein gutes bis sehr gutes Resultat erzielt werden. Allerdings fällt die Erfolgschance beim Vorliegen fortgeschrittener degenerativer Veränderungen, welche eine Grad-1-Arthrose nach Tönnis überschreiten, rapide ab. Der Erhalt des Labrums hat einen signifikanten Einfluss auf das klinische Ergebnis und die radiologische Progression der Arthrose. Das Erhalten des Labrums scheint deshalb unabdingbar zu sei

CT changes after trochleoplasty for symptomatic trochlear dysplasia

Trochlear dysplasia is an important risk factor for patellar instability. Because of a decreased trochlear depth in combination with a low lateral femoral condyle, the patella cannot engage properly in the trochlea. Trochleoplasty is a surgical procedure, which strives to correct such bony abnormalities. The aim of this study was to describe morphological features of trochlear dysplasia and the corrective changes after trochleoplasty on CT scan. The study group consists of 17 knees with trochlear dysplasia having undergone trochleoplasty for recurrent patellofemoral dislocation at a mean age of 22.4years. The evaluation consisted in pre- and postoperative measurements on the proximal and distal trochlea on transverse CT scans in order to determine the morphological features. We measured the transverse position and depth of the trochlear groove, the transverse position of the patella, the ratio between the posterior patellar edge and the trochlear groove, the lateral patellar inclination angle, the sulcus angle, and the lateral trochlear slope. The trochlear groove lateralised a mean of 6.1mm in the proximal aspect and 2.5mm in the distal aspect of the trochlea, while the patella medialised a mean of 5mm. Preoperatively the patella was lateral in relation to the trochlear groove in 13 cases, neutral in two cases, and medial in two cases. Postoperatively it was lateral in four cases, in neutral position in seven cases, and medialised in six cases, referenced to the trochlear groove. The trochlear depth increased from 0 to 5.9mm postoperatively in the proximal aspect of the trochlea, and from 5.5 to 8.3mm postoperatively in the distal trochlea. The lateral patellar inclination angle decreased from a mean of 21.9° to a mean of 7.8°. The sulcus angle decreased from a mean of 172.1° to a mean of 133° in the proximal trochlea and from a mean of 141.9° to a mean of 121.7° in the distal trochlea. The lateral trochlear slope changed from 2.8° to 22.7° in the proximal and from 14.9° to 26.9° in the distal part of the trochlea. In the CT scan patients with trochlear dysplasia demonstrated a poor depth, or even a flat or convex trochlea with a greater sulcus and lateral trochlear slope angle, a lateralised patella to the trochlear groove with poor congruency, and a greater lateral patellar inclination angle. Trochleoplasty can correct the pathological features of trochlear dysplasia by surgically creating more normal anatomy. The goal of this surgical procedure is to steepen and lateralise the trochlear groove for a better engagement of the patell

The Orthopaedic forum 2011 Austrian-Swiss-German traveling fellowship tour summary

From January 31st to March 11th 2011 four traveling fellows representing the German speaking associated orthopaedic societies visited different academic orthopaedic centers in the U.K., Canada and the USA

Elongation Patterns of Posterolateral Corner Reconstruction Techniques: Results Using 3-Dimensional Weightbearing Computed Tomography Simulation

Background The isometric characteristics of nonanatomic and anatomic posterolateral corner (PLC) reconstruction techniques under weightbearing conditions remain unclear. Purpose To (1) simulate graft elongation patterns during knee flexion for 3 different PLC reconstruction techniques (Larson, Arciero, and LaPrade) and (2) compute the most isometric insertion points of the fibular collateral ligament (FCL) graft strands for each technique and report quantitative radiographic landmarks. Study Design Descriptive laboratory study. Methods The authors performed a 3-dimensional simulation of 10 healthy knees from 0° to 120° of flexion using weightbearing computed tomography (CT) scans. The simulation was used to calculate ligament length changes during knee flexion for the PLC reconstruction techniques of Larson (nonanatomic single-bundle fibular sling reconstruction), Arciero (anatomic reconstruction with additional popliteofibular ligament graft strand), and LaPrade (anatomic reconstruction with popliteofibular ligament graft strand and popliteus tendon graft strand). The most isometric femoral insertion points for the FCL graft strands were computed within a 10-mm radius around the lateral epicondyle (LE), using an automatic string generation algorithm (0 indicating perfect isometry). Radiographic landmarks for the most isometric points were reported. Results Median graft lengthening during knee flexion was similar for the anterior graft strands of all 3 techniques. The posterior graft strands demonstrated significant differences, from lengthening for the Arciero (9.9 mm [range, 6.7 to 15.9 mm]) and LaPrade (10.2 mm [range, 4.1 to 19.7 mm]) techniques to shortening for the Larson technique (-17.1 mm [range, -9.3 to -22.3 mm]; P < .0010). The most isometric point for the FCL graft strands of all techniques was located at a median of 2.2 mm (range, -2.2 to 4.5 mm) posterior and 0.3 mm (range, -1.8 to 3.7 mm) distal to the LE. Conclusion Overconstraint can be avoided by tensioning the posterior graft strands in the Larson technique in extension, and in the Arciero and LaPrade techniques at a minimum of 60° of knee flexion. The most isometric point was located posterodistal to the LE. Clinical Relevance The described isometric behavior of nonanatomic and anatomic PLC reconstruction techniques can guide optimal surgical reconstruction and prevent graft lengthening and overconstraint of the lateral compartment in knee flexion. Repetitive graft lengthening has been found to be associated with graft failure, and overconstraint favors lateral compartment pressure and cartilage degeneration

Elongation Patterns of the Superficial Medial Collateral Ligament and the Posterior Oblique Ligament: A 3-Dimensional, Weightbearing Computed Tomography Simulation

Background Although length change patterns of the medial knee structures have been reported, either the weightbearing state was not considered or quantitative radiographic landmarks that allow the identification of the insertion sites were not reported. Purpose To (1) analyze the length changes of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) under weightbearing conditions and (2) to identify the femoral sMCL insertion site that demonstrates the smallest length changes during knee flexion and report quantitative radiographic landmarks. Study Design Descriptive laboratory study. Methods The authors performed a 3-dimensional (3D) analysis of 10 healthy knees from 0° to 120° of knee flexion using weightbearing computed tomography (CT) scans. Ligament length changes of the sMCL and POL during knee flexion were analyzed using an automatic string generation algorithm. The most isometric femoral insertion of the sMCL that demonstrated the smallest length changes throughout the full range of motion (ROM) was identified. Radiographic landmarks were reported on an isometric grid defined by a true lateral view of the 3D CT model and transferred to a digitally reconstructed radiograph. Results The sMCL demonstrated small ligament length changes, and the POL demonstrated substantial shortening during knee flexion (P = .005). Shortening of the POL started from 30° of flexion. The most isometric femoral sMCL insertion was located 0.6 ± 1.7 mm posterior and 0.8 ± 1.2 mm inferior to the center of the sMCL insertion and prevented ligament length changes >5% during knee flexion in all participants. The insertion was located 47.8% ± 2.7% from the anterior femoral cortex and 46.3% ± 1.9% from the joint line on a true lateral 3D CT view. Conclusion The POL demonstrated substantial shortening starting from 30° of knee flexion and requires tightening near full extension to avoid overconstraint. Femoral sMCL graft placement directly posteroinferior to the center of the anatomical insertion of the sMCL demonstrated the most isometric behavior during knee flexion. Clinical Relevance The described elongation patterns of the sMCL and POL aid in guiding surgical medial knee reconstruction and preventing graft lengthening and overconstraint of the medial compartment. Repetitive graft lengthening is associated with graft failure, and overconstraint leads to increased compartment pressure, cartilage degeneration, and restricted ROM

Haemophilic knee arthropathy: long-term outcome after total knee replacement

Purpose: The objective of this study was to evaluate the long-term outcome and prosthetic survival of primary total knee arthroplasty in haemophilic patients. It was hypothesized that the infection and revision rate are higher and the outcome inferior when compared with patients without haemophilia. Methods: Between 1985 and 2004, forty-three consecutive primary total knee replacements were performed in thirty haemophilic patients. These patients' charts were reviewed retrospectively. Twenty-five patients (34 knees) were available for clinical and radiological follow-up. The outcome was assessed using the Knee Society score, WOMAC and Kaplan-Meier survivorship analysis. Results: An haematogenous infection occurred in two patients. In three patients, component revision was needed: two because of an infection and one because of a mechanical failure. After a mean follow-up of 9.6years (2-20), 94% of the patients rated their result as either excellent or good. At time of follow-up, the Knee Society Score averaged 73.3 points (range, 29-100) and showed a significant gain (p<0.001) compared to preoperative. Flexion contracture could be reduced significantly (p<0.001) from 18.1° preoperatively to 8.4° at follow-up, whereas flexion remained unchanged. When infection or any component replacement was set as endpoints, the 10years prosthetic survival was 90 and 86%, respectively. Conclusion: Total knee arthroplasty in haemophilic patients is a reliable treatment that results in pain relief and functional improvement with a low risk of postoperative infection. However, neither the postoperative infection rate nor the functional result does reach the same level as in a population not affected by haemophilia. Level of evidence: I

Experimental loss of menisci, cartilage and subchondral bone gradually increases anteroposterior knee laxity

Purpose: Anteroposterior knee stability is a relevant factor for the decision-making process of various surgical procedures. In degenerative joints when the implantation of unicompartimental prostheses or corrective osteotomies of the limb are planned, the integrity of the anteroposterior stability with an intact ACL has been regarded as a necessary prerequisite. We hypothesise that joint degeneration, however, may influence the anteroposterior knee laxity. Therefore, we set out to test this hypothesis simulating a progressively ‘degenerated' joint in an experimental cadaveric setting. Methods: Twelve intact transfemorally resected Thiel-fixated cadaver knee joints were divided into 2 groups for manipulation in the medial or lateral compartment. In each knee, we performed (1) unilateral total meniscectomy; (2) simulation of advanced osteoarthritis, by unilateral total cartilage debridement; (3) simulation of a unilateral tibial impression fracture, by resection of 5mm of the tibial plateau; (4) transection of the ACL. The KT-1000 arthrometer was used to measure the extent of anteroposterior translation at 30° of knee flexion. Results: The mean value for tibial anteroposterior translation before intervention was 3.2mm (SD: ±0.8). The mean translation after each intervention was 4.6mm (SD: ±0.9; +44%; n.s.) after meniscectomy, 5.9mm (SD: ±1.5; +84%; P<0.05) after cartilage debridement, 8mm (SD: ±1.5; +150%; P<0.01) after bone debridement, and finally 9.7mm (SD: ±2.2; +203%; P<0.05) after resection of the ACL. There were no significant differences between the medial and lateral compartment. Conclusion: In absence of massive osteophytes or capsular shrinkage, rapid loss of meniscus, cartilage and particularly loss of subchondral bone may result in a massive increase in anteroposterior translation, mimicking a tear of the ACL. In such a situation, a false positive impression of a ligamentous injury may arise, and decision making is falsely directed away from totally or partially knee joint-preserving procedures. Therefore, in degenerate joints, clinical evaluation of anteroposterior stability should rather rely on the presence of a firm stop than an overall increased joint translatio