Joint fractures

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Arthroscopy: The Journal of Arthroscopic & Related Surgery Online

October 1999, Supplement 1 • Volume 15 • Number 7

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Joint Fractures AGA Abstracts

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1. Arthroscopic and Histomorphologic Analysis of Failures in the Surgical Treatment of Chronic Cartilage Defects.

S. Nehrer M. Spector T. Minas Vienna/Boston.

Joint Fractures

Surgical treatment of chronic cartilage defects includes abrasion arthroplasty (AAP), the transplantation of chondrogenous tissue such as perichondrium (PCH), as well as a newly developed technique, implanting a cell suspension of cultivated, autologous chondrocytes (ACI) under a periostal flap sutured to be water-tight. This study compares arthroscopic findings with histomorphologic analyses of tissues in chronic cartilage defects after unsuccessful operations, and analyzes the mechanism of these failures and complications. 20 patients with unsuccessful outcomes following surgical treatment of cartilage defects underwent prospective clinical examination (KS-Score) and the cartilage defect was arthroscopically documented (Bauer et al.). The intervals to previous treatment were 21 + 4 months for AAP, 31 + 8 months for PCH and 3 + 1 months for ACI. In 22 revision operations (2 knee TEP, 14 ACI and 6 complications after ACI), the tissue in the defect was removed in one piece whenever possible, fixated and embedded in paraffin for histological follow-up. Histomorphometric analysis of the tissue types as well as immune histochemistry for types I, II and X collagen were carried out. The material in the defect after AAP showed fibrous, sponge-like tissue (22 + 9%) with type I collagen as well all degenerating, cartilage-like tissue with type II collagen. After PCH we found a

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Arthroscopy: The Journal oi: Arthroscopic & Related Surgery Online

marked ossification process (19 + 6%) in the zone where the perichondrium had been implanted, with elevation of the subchondral lamina and rarification of the cartilage layer. Positive staining for type X collagen in the pericellular matrix of hypertrophic cartilage cells indicated progressive enchondral ossification. The earlier revisions after ACI were generally due to partial detachment of the periostal flap from the subchondral bone or adjacent cartilage. In the detached zones, we found mainly fibrous tissue (55 + 1%), while the periosteum in the stable, adherent zones had undergone transformation to hyaline tissue (up to 12%). The histological tissue analysis of chronic cartilage defects after failed surgical treatment revealed specific histological patterns of tissue composition and appears essential for the evaluation of surgical techniques for cartilage defects.

2. Clinical Results of Autologous Chondrocyte Implantation for the Treatment of Cartilage Defects of the Knee Joint.

C. Erggelet F. Fu B. Mandelbaum Freib u rg/Pitt sb urg h.

Joint Fractures

Joint cartilage defects in adolescents are of substantial medical as well as socio-economic importance, which is further enhanced considering the danger of premature arthrosis. Different methods of therapy for such defects have been have been described, some more successful than others. Amoung the methods of therapy with a biological approach, i.e., aiming for the regeneration of hyaline cartilage, the implantation of autologous chondrocytes (ACl) by Brittenberg is in clinical use. With the goal to judge the efficiency and safety of ACl, an outcome study in which 227 surgeons in the US and Europe have been participating so far, was initiated in 1995. By March 31st, 1997, these surgeons reported on 951 patients who had undergone cartilage biopsy in the aim to treat a cartilage defect of the knee joint by ACl. 76% of the patients had had previous surgery at least once. The patients were 69% male and the majority (97%) was between 15 and 55 years of age. The men had an average body weight of 89 kg and a height of 180 cm. In comparison, the women were shorter (165 cm) and lighter (73 kg). 312 patients (315 knees) underwent autologous chondrocyte implantation, most of them (95%)with grade Ill/IV defects of 4.1 cm 2 on the average and 60% located in the medial femur condyle (16% lateral). 18% of the knees had more than one defect. After 6 (n = 215) and 12 (n = 91 ) months, the clinical outcome of the operation was graded and evaluated by means of a modified Cincinnati Knee Score. At 6.9 (1 = poor and 10 = excellent), the mean score value after 12 months was significantly P>.001) higher than before the operation at 3.2. An improvement was also found between the 6th and the 12th postoperative month (5.6 to 6.9). The scores for pain and swelling also improved significantly. The clinical examination after 12 months showed a decrease in knee joint pain, swelling and crepitus P<.002 each). A total of 85% of the patients reported an improvement after 12 months, while 11% said their condition had deteriorated. In 4.6% of the cases complications arose, regarded by the the attending surgeons as possible consequences of ACl. Mainly fibro-arthrosis, implant hypertrophy and implant detachment were reported. Ossification of the implant was not observed.

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In summary, these data support the first encouraging results reported by Brittenberg and co-workers in 1994, presuming autologous chondrocyte implants to be an effective and safe method of therapy for deep cartilage defects of the knee joint. Comparable studies on other modes of therapy and further data from the ongoing study will be necessary to determine the ultimate value of this technique.

3. Changes of Cartilage Following Osteochondral Accompanying Lesions Initially Documented by Nuclear Magnetic Tomography in Ligament Injuries of the Knee Joint.

A. Lahm C. Erggelet A. Reichelt Freiburg.

Joint Fractures

Concept: Since the use of nuclear magnetic tomography for diagnostics of the limbs and joints, the importance of initially radiologically occult sub- and osteochondral accompanying lesions in ligament injuries of the knee joint is becoming increasingly clear. It is a fact that, in spite of adequate treatment of capsular and ligament ruptures, a number of patients develop degenerative changes of the knee joint over the years without an obvious reason. Materials and Methods: A total of 190 knee joints, 134 of which had traumatic internal lesions, were examined during the years 1993-1996 by nuclear magnetic tomography. In 44 cases various chondral or osseous changes were found. In addition to standardized T1- and T2-weighted MRI sequences, STIR (short time inversion recovery) and 3D-GE (gradient echo) sequences were employed. Arthroscopy of the affected knee joint was performed in 34 of these 44 patients with osseous or chondral changes. 35 times another nuclear magnetic tomography as well as a clinical examination were carried out after at least 6 months. In 8 cases cartilage biopsies were gained from non-weight- bearing areas or from cartilage transplants. This material was examined for degerative changes such as unmasking and rupture of collagenous fibers. Results: 10 patients showed subchrondral fractures of the tibia plateau and femur, some of which revealed arthroscopically visible signs of caving in and dislocation. 5 osteochrondral fractures were associated with ACL-ruptures. The chondral/bony fragments were either inpacted or dislocated. The so- called bone-bruise, spongeous bone-edema, was found in 25 cases, 16 of which were associated with ruptures of the anterior cruciate ligament. These are low in signal intensity in the T1 image and high in signal intensity in the T2 and the STIR images. 4 further patients showed stress fractures. Altogether, the incidence of ligament injuries was strikingly high (76.5%). In the follow-up nuclear magnetic tomographies, there was a marked decrease in spongeous bone edemas. However, a large share of the other lesions were still visible and some were progressive. The cartilage biopsies generally showed various degrees of degenerative changes. Conclusions: Obviously different traumatic lesions of the spongy and subchondral bone are at least a partial indicator for chondral damage later on. This knowledge may offer valuable impulses for the modification of rehabilitation (isokinetics, OKC = open kinetic chain, ortheses with compartmental pressure removal).



4. Traumatic Versus Degenerative Cartilage Lesions of the Knee Joint.

K. Labs H. U. Walther D. Peter Berlin.

Joint Fractures

After over two decades of endoscopic surgery, cartilage lesions of the knee joint stilll represent a challenge for every surgeon. The therapeutic options are limited and sufficiently well-known. The aim of this retrospective study was to throw more light upon the question, which forms and Iocalizations of lesions are typical for the knee joint, regarding their differences in genesis. The patients recruited for this investigation had presented with traumatic or degenerative cartilage damage between 1988 - 1996. The inclusion criteria were isolated rupture of the anterior cruciate ligament with a cartilage lesion for traumatic changes and isolated cartilage lesion without indication of traumatic origin for degenerative changes. A total of 572 patients with cartilage lesions due to trauma and instability and 976 patients with degenerative cartilage lesions were analyzed regarding the compartment and grade of their defects. Grading (grade I-III) of defects was carried out in accordance with a modified classification similar to the one defined by Outerbridge and Jackson. Taking all cartilage defects into consideration, the traumatic lesions were found to be localized primarily on the medial tibia plateau (64.7%) and the medial femur condyle (61.3%). The least involvement was found in the patello-femoral joint (24.9%) and the lateral tibia plateau (52.1%). The highest degree of damage appeared primarily on the medial femur condyle (11.2%), while the medial tibia plateau showed the lowest degree (51.2%). In contrast to this, the percentage of degenerative lesions was highest on the medial tibia condyle (76.6%), the patella (75.7%) and the medial femur condyle (72.4%). The least marked changes by far were most frequent on the medial tibia plateau (44.8%). In the patellar region (36.0%) there was a predominance of grade II changes. The most serious cartilage defects (grade III) were documented for both groups on the medial femur condyle (11.2% traumatic, 27.3% degenerative). The following conclusions may be drawn from the data gained: the lesions forms are genesis-specific. The share of post-traumatic minor cartilage damage is relatively high in the medial tibia zone, localized mainly in the dorsal area towards the intercondylar region. The degenerative damage in this region is localized mainly parameniscally and in the main weight-bearing zone. As was to be expected, the degenerative cartilage lesions show a much greater share of damage in the retropatellar area and the patello-femoral joint than the traumatic lesions. Traumatic cartilage lesions of the patella represent a minority only.

5. Mid-Term Outcomes Following Arthroscopically and Radiologically Assisted Osteosynthesis of the Tibial Head.

W. Attmanspacher J. Linz H. W. Stedtfeld Nuremberg.



Joint Fractures

Arthroscopically and radiologically assisted treatment of fractures of the tibial head has become one of the standard procedures in arthroscopic surgery of the knee joint. At our institution it has been performed consistantly since January 1992. The aim of this study was to check the outcome of our arthroscopically assisted osteosyntheses in this patient collective and to determine whether the patients we had treated surgically were able to regain and maintain the same level of activity in sports and daily life. Materials and Methods: Between Jan. 1st, 1992 and Dec. 31st, 1996, 29 patients with fracture of the tibial head underwent arthroscopically assisted surgery at our institution. 104 patients had conventional surgery during the same period of time. The indications for arthroscopically assisted tibial head osteosynthesis were fissured fractures, monocondylar impression-depression fractures, as well as slightly dislodged dislocation and C-fractures. In 19 of the 39patients undergoing arthroscopically assisted surgery, arthroscopy had intraoperative therapeutic consequences (10 partial meniscus resections, 4 meniscus sutures, 7 operations on the joint cartilage, 4 resections of the cruciate ligament stump) (in combination). In the simple fissured fractures we did not see any cases of accompanying pathology of the menisci or ligaments requiring therapeutic measures. Impression- depression fractures were elevated through fenestration from the opposite side and lined with hydroxyle apatite and/or autologous spongiosa if necessary. Osteosynthesis was performed with cannulated screws. In 7 cases we saw intra- and postoperative complications. In 21 patients the osteosynthesis material has since been removed. A re-arthroscopy was necessary in 3 of these patients (two partial meniscus resections, 1 operation on the joint cartilage). We followed up 29 arthroscopically operated patients clinically and radiologically, evaluating them according to the Lysholm score. In our opinion this score is well suited for the evaluation of fractures of the tibial head. The x-rays done were used to determine the stage of arthrosis and for the evaluation of plateau widening according to Rasmusen. Results: The follow-up examination was carried out after an average of 26 months. Subjective evaluation of the surgical outcome was good or excellent in 25/29 cases. 4 patients evaluated the surgical outcome as poor. The reasons for this were 2 postthrombotic syndromes, 1 remaining meniscus lesion and 1 partial paresis of the peroneal nerve. The average outcome according to the Lysholm score was around 84. Most patients were able to resume their jobs and their sports. The average period of inability to work following osteosynthesis was 11 weeks in our patient collective. Of the patients with anterior cruciate ligament insufficiency, two required a secondary surgical replacement of the anterior cruciate ligament. However, complaints during everyday activity were the exception in our patients. Radiologically we saw stage I arthrosis in 11 patients and to date the remaining patients have not shown any radiological signs of arthrosis of the knee joint. Conclusion: Arthroscopically and radiologically assisted osteosynthesis of the tibial head enabled our patients to return to work at an early point and their perioperative morbitdity, judged by the amount of analgetics required, was markedly lower than in patients undergoing conventional surgery for fractures of the tibial head. In 19 patients, arthroscopy revealed accompanying intra-articular pathology with therapeuticconsequences. In isolated, non-dislocated fissured fractures (type B 1.1), arthroscopy had no further consequences and we therefore consider it dispensible. The removal of osteosynthesis material is indicated only if the implant is causing complaints and in young patients.

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6. Evaluation of Arthroscopically Assisted Minimal Osteosynthesis of Tibial Head Fracture.

A. Kovacs S. Szekeres G. Me~n~ Budapest.

Joint Fractures

A retrospective study was carried out to evaluate the early and late outcome of closed reposition and arthroscopically assisted minimal osteosynthesis. Materials and Methods: 573 patients with tibial head fracture were treated in our department between 1987 and 1997.204 patients underwent operations. The surgical technique was closed reposition with elevation of the joint surface through a percutaneously trepanated opening under the tibial head. This method was first performed in patients polytrauma, advanced age and local soft tissue problems, and later in other cases also. 121 patients were treated altogether. Arthroscopic follow-ups were carried out in 33 cases. The reposition was stabilized with spongiosa screws and/or Kirschner wires. Spongiosa plasty was also performed when necessary. Postoperative treatment was carried out without weight- bearing with dynamic knee orthesis. In individual cases arthroscopy was also performed during the removal of osteosynthesis material. Results: The infection ratio was 1.5% as opposed to 5% for operations previously performed for similar fractures. The radiological/anatomical results were as follows: excellent (anatomical reposition): 82/121, good (dislocation < 1 mm): 26/121, satisfactory (dislocation: 1-2 mm): 9/121, poor (dislocation > 2 mm): 4/121. The following range of function was found after 3 months of postoperative therapy in flexion: 0/90 degrees: 11/121, full function: 68/121. The Lysholm Score reached an 80 point average in the course of one year. Conclusion: Except for treatment of combined infracondylar fractures and dislocation fractures, this method was found to be good. Articular rinsing appears to be an advantage also. The functional results were good, but in the late outcome, elderly patients showed characteristic signs of (not just posttraumatic) osteoarthrosis. This technique is less stressful and lends itself better to arthroscopic control.

7. Mid- to Long-Term Outcomes Following Arthroscopically Treated Fracture of the Tibial Head.

K. P. Benedetto C. Fink W. Hackl C. Briglauer Innsbruck.

Joint Fractures



Arthroscopically assisted treatment of joint fractures is growing increasingly important in minimally invasive surgery and has proven useful for a wide spectrum of indications, particularly in the knee joint. The aim of the present study was to evaluate the minimum 5-year outcome after assisted osteosynthesis of fractures of the tibial head, taking the learning curve into additional consideration. Materials and Methods: Between 1990 and 1993, 19 patients (10 male, 9 female, age distribution 20 to 76 years, average 55.3 years) underwent arthroscopically assisted surgery for fracture of the tibial head. These patients were personally followed-up clinically and radiologically after a minimum observation period of 5 to 8 years (mean value 6.05 years). According to the AO Classification, three fractures were B1, five B2, eight B3, one C2 and two C3. The side distribution was 11 left and eight right. 15 patients presented with isolated mono-trauma, three had multiple injuries and there was one case of polytrauma. The cause of injury was skiing in seven cases, soccer once, traffic accident in eight cases, fall from a height twice and working accident once. Surgical treatment was carried out on the day of the accident in five cases, one day later in four cases, during the first week in eight patients and after the first week in only two patients. Stabilization was accomplished by means of screws alone in 13 cases and in six cases additional plate stabilization was carried out after screw fixation of the tibia plateau. Results: In the modified OAK Score, the pain score reached 43.4 points of a 50 point maximum. Regarding mobility, the score was 23.1 of 25 possible points. In step climbing, it was 46.9 of an average of 50 possible points and the total functional evaluation scored 43.2 of 50 possible points. Regarding the evaluation of the bone axis position, 13 patients showed an bilaterally identical satisfactory result, six patients had a deviation with a valgus of 5 ° at maximum and one patient had over 5 ° valgus.according to the Fairbank Scale showed Fairbank 0 in four cases, Fairbank I in six cases, Fairbank II in five cases and Fairbank III in four cases. Widening of the lateral tibia plateau was seen in two cases. A re-operation was performed in three cases, requiring secondary lateral partial meniscus resection in once case, bridle resection due to intra-articular adhesions in one case and removal of a loose body in one case. Conclusions: Arthroscopically assisted treatment of lateral fracture of the tibial head has a good outcome, provided the tibial plateau is not merely elevated, but can also be supported by a permanent lining. Reconstruction of the original widening and particularly permanent correction of the axis-- especially in the Valgus Morpho typemis decisive for a good prognosis in surgical treatment of lateral tibial head fracture.

8. Mid-Term Outcome Following Arthroscopic Treatment of Fresh Distal Intra-Articular Fractures of the Radius.

G. Peicha F. J. Seibert M. Fellinger W. Grechenig Graz.

Joint Fractures

The aim of the study was to gain mid-term data on the outcome of arthroscopically assisted therapy of distal intra-articular fractures of the radius.



Materials and Methods: Since 1993, 30 patients with fresh, distal, intra-articular fractures of the radius have undergone arthroscopically assisted treatment at our institution. These were 3B and 27C fractures according to the AO Classification, and mainly group VII and VIII fractures according to Frykman. Closed reposition of the fractures under arthroscopic viewing and fixation by percutaneously inserted K-wires, cannulated screws or threadede K-wires were carried out. Immobilization was accomplished by means of a joint spanning external fixator or a plaster cast on the forearm for 4 - 6 weeks. Whenever additional injuries of the intrinsic ligaments of the TFCC complex were diagnosed, they were seen to during the same session. 23 of 25 patients (92%) who had undergone surgery at least 12 months earlier, were followed up after an average period of 32.5 months. The clinical examination included range of motion, gripping strength and subjective well-being. Additionally, anterioposterior and lateral x-rays were done as well as stress images in radial and ulnar abduction. The data were evaluated according to the scores of Cooney and Jakim, respectively. Results: Wrist arthrosis (evaluated according to Knirk et al.) was grade 0 in 6 cases, grade 0-1 twice, grade I 10 times, grade I-II 3 times, grade III once. The radio-carpal angle was physiologic in all but 2 cases. The gradient of the distal joint surface of the radius was physiologic 12 times, neutral 7 times and dorsally tilted 4 times (5 ° twice, 10 ° twice). The average range of motion in comparison to the opposite side was slightly impaired, but did not differ significantly. The average gripping strength did not show a significant difference in injuries to the non-dominant hand. 19 patients were subjectively very satisfied to satisfied with the outcome and only 4 patients reported little satisfaction. Conclusion: According to our experience, patients undergoing arthroscopic treatment of distal intra- articular fractures of the radius show satisfactory mid-term outcomes.


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Joint fractures

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