Progress in Orthopaedic Surgery. Vol. 3

Transcription

1 Progress in Orthopaedic Surgery Vol. 3 Editorial Board N. Gschwend, Zurich' D. Hohmann, Erlangen. J. L. Hughes, Jackson' D. S. Hungerford, Baltimore' G. D. MacEwen, Wilmington E. Morscher, Basel J. Schatzker, Toronto H. Wagner, N uremberg/ Altdorf. U. H. Weil, New Haven

2 The Knee: Ligament and Articular Cartilage Injuries Edited by D. E. Hastings Contributors w. Bandi, Interlaken. D. Baumann, Munich. C. Burri, VIm H. Cotta, Heidelberg. R. Ganz, Berne. W. Glinz, Zurich L. Gotzen, Hannover. M. H. Hackenbroch, Munich M. Haring, Freiburg. G. Helbing, VIm H. R. Henche, RheinfeldenlBaden. P. Hertel, Homburg/Saar I. Hesse, Hannover W. Hesse, Hannover E. H. Kuner, Freiburg L. Leichs, Munich. E. Morscher, Basel. J. Miiller, Liestal W. Miiller, Basel G. Muhr, Hannover W. Puhl, Heidelberg H. J. Refior, Munich J. Rehn, Bochum. A. Riiter, VIm I. Schneider, Bochum. L. Schweiberer, Homburg/Saar W. Spier, VIm D. Terbriiggen, Freiburg H. Tscherne, Hannover. H. Willenegger, Berne With 139 Figures Springer-Verlag Berlin Heidelberg New York 1978

3 Guest Editor: D. E. Hastings, Suite 613, 1849 Yonge Street, Toronto, Ontario M4S 1 Y2, Canada ISBN-13: e-isbn-13: : / Library of Congress Cataloging in Publication Data. Reisensburger Workshop zur Klinischen Unfallchirurgie, 3d-4th, The knee. (Progress in orthopaedic surgery; v. 3) Selected papers of the 3d and 4th Reisensburg Workshop held Feb. 27-Mar. 1, and Sept , Includes bibliographies and index. 1. Knee - Wounds and injuries - Congresses. 2. Ligaments - Wounds and injuries - CongrL''''''.. \rlicular cartlage - Wounds and injuries - Congresses. I. Hastings, David Erich, II. Bandi, W, III. Title. IV. Series. RD561.R b 611' This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Under 54 of the German Copyright Law where copies are made for other than private use, a fee is payable to the publisher, the amount of the fee to be determined by agreement with the publisher. Springer-Verlag Berlin Heidelberg 1978 Softcover reprint of the hardcover 1st edition 1978 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Typesetting: E. Kieser KG, Augsburg 2120/

4 Contents Preface VII Introduction IX Biomechanics and Pathophysiology 1 P. Hertel, L. Schweiberer: The Biomechanics and Pathophysiology of the Knee Ligaments 1 H. Cotta, W. Puhl: The Pathophysiology of Damage to Articular Cartilage 15 H. J. Refior, M. H. Hackenbroch jr.: The Reaction of Articular Cartilage to Pressure, Immobilization and Distraction 33 The Acute Knee Ligament Injury 45 G. Muhr, H. Tscherne, L. Gotzen: The Treatment of Acute Knee Ligament Injuries 45 C. Burri, G. Helbing, W. Spier: The Rehabilitation of Knee Ligament Injuries 53 Chronic Knee Ligament Instability 59 W. Muller: Rotational Stability of the Knee 59 G. Helbing, A. Ruter, C. Burri: The Treatment of Unstable Knees 75 I. Schneider, J. Rehn: Pedicled Grafts in the Treatment of Unstable Knees 81 J. Muller, H. Willenegger, D. Terbruggen: Free Autologous Skin Grafts in the Treatment of the Unstable Knee 87

5 VI Contents The Acute Cartilage Injury 95 w. Glinz: Arthroscopy in Articular Cartilage Injury 95 E. Morscher: Posttraumatic Cartilage Impression of the Femoral Condyle 105 R. Ganz: The Isolated Shear Injury to Articular Cartilage 113 E. H. Kuner, M. Haring: Internal Fixation of Osteochondral Fragments 117 The Old Cartilage Injury 121 W. Hesse, I. Hesse: An Experimental Basis for Cartilage Transplantation 121 W. Muller: Osteochondrosis Dissecans 135 Retropatellar Cartilage Degeneration 143 A. Ruter, C. Burri: Retropatellar Cartilage Degeneration: Diagnosis and Outline of Treatment 143 H. R. Henche: Patellar Shaving (Indications, Technique, Results) 157 D. Baumann, L. Leichs: Retinacular Release: Indications, Technique, Results 165 W. Bandi: Anterior Displacement of the Tibial Tuberosity 171 Subject Index 183 List of Contributors 189

6 Preface The editorial group has selected these papers for publication in Progress in Orthopaedic Surgery from contributions to the "Reisensburg Workshop of Clinical Trauma Surgery" dealing with the lesions of knee ligaments and cartilage in They represent a survey of today's knowledge of pathophysiology, diagnostic means, and therapy of these lesions in the German-speaking countries. There are two "Reisensburg Workshops" annually, covering current topics of traumatology sponsored by the Ulm trauma group. Primary attention is focused not upon review lectures but rather upon the extensive discussions thus resulting in recommendations to the practising trauma surgeon in order to facilitate his clinical work. Ulm, November 1977 C. Burri, A. Ruter

7 Introduction This volume of Progress in Orthopaedic Surgery presents a selection of papers dealing with injuries to the ligament support and articular surfaces of the knee. The menisci are not discussed as separate entities, but rather in their correct perspective as part of the knee jointsupport mechanism. As the editor for this volume, I have tried to select the most representative articles which cover this subject. These are publications from our European colleagues and reflect their opinion and experience. I have tried not to change their content or meaning in any way. This volume has been divided into six basic segments. Each deserves comment. The concept of the four-jointed chain system is a difficult one to grasp, but is sound on an engineering basis. It is clear from this key interaction of the cruciate ligaments how the loss of one cruciate will lead to a profound alteration in knee mechanics. Many authors suggest that the loss of stability from an isolated anterior cruciate ligament may be minimal, but I think that this article demonstrates the possibility of severe complications occurring in the later stages. Changes in articular cartilage detected under electron microscopy are irreversible after a short period of immobilization, especially in full extension. This experimental work reinforces the potential value of the cast brace or limited motion plaster. The acute knee ligament injury is discussed only briefly in this volume. Unfortunately there was no article which adequately stressed the major problem with the acutely injured knee, namely the recognition of the severity of the original injury. The vast experience accumulated by North American surgeons on reconstructing chronically unstable knees suggests that our treatment of the acutely in jured knee is less than optimal. The "relatively" isolated anterior cruciate tear that shows a history of a pop and a rapid hemarthrosis is seldom recognized. Severe disruptions including the medial ligament complex and the anterior cruciate ligament are often missed and lead to late complex instability. The treatment of the isolated collateral tear is still controversial. Even in Europe there is debate as to whether the optimal treatment is operative repair or immobilization. The diagnosis of such an injury often requires a general anesthetic to rule out an associated cruciate lesion. If the collateral lesion is isolated, then I would feel that many can be managed nonoperatively and that the limited motion plaster presents an ideal technique for this. Chronic knee ligament instability is a subject that is familiar to most orthopaedic surgeons in North America. The concept of rotational instability has gained wide acceptance on both sides of the ocean. Many tissues are available for reconstructing the unstable knee. Certainly the pedicle graft using the biceps

8 x Introduction orr the'lateral"side, a portion olti)'e pes on the medial side, and portions of the patellar tendon for cruciate problems are all valuable adjuncts to a capsular repair. Of particular interest to me was the use of skin as an autologous ligament substitute. Although the authors have not carried out a large number of reconstructions over the years, their results appear acceptable. The use of skin could be an adjunct to other pedicle grafts in severe ligament disruptions. This is an area for further exploration and e ~ p e r i m e n t a t i o n. k Acute-injuries to the articular surface of the knee 'are often underestimated in comparfoon with meniscal or ligament damage. The series of papers dealing with this subject clearly show that the shearing injuries removing either a cartilage cap from the underlying subchondral bone or the more common osteochondral fracture can be replaced and will heal, restoring a normal cartilage surface. The entity of cartilaginous impression of the femoral condyles is an interesting concept. It is difficult to determine when it is a normal anatomic variant or a pathological entity. Drs. Hesse and Hesse have presented very clearly an experimental basis for cartilage transplantation. In particular their meticulous work on electron microscopy suggests that the cell death in homographs is not visible by normal histologic methods. On the other hand, autologous cartilage transplantation from adjacent areas should stand a high chance of success. this is obviously why the replacement of an osteochondral fragment and large areas of osteochondrosis dissecans are likely to meet with success. The secure fixation of these fragments and the early motion of the knee are clearly the two main factors that ensure success. The entity of chondromalacia and subsequent patellofemoral arthritis remains a common and difficult problem. The diagnosis is often not as easy as might be suggested. All the authors, however, stress the importance of two basic etiologic factors, an abnormal gliding pathway or an abnormal gliding surface. The toughness of articular cartilage appears to be due to the tangential fibers on its surface. Once these are unmasked by shaving, the concept of increased pressure accelerating wear must be considered. Anterior displacement of the tibial tubercle combined with retinacular release appears to offer the most efficient method of dealing with the problem. This third volume of Progress in Orthopaedic Surgery has-tried to follow the aims of previous issllcs. Thc work of our German-spcaking collcagues should be shared with their North American counterparts, so that each may profit from the other. Toronto, November 1977 D. E. Hastings