No abstract

Operative anatomic reconstruction of the injured acromioclavicular joint leads to very good clinicofunctional outcomes. The operative technique plays only a minor role in achieving these outcomes. The rate of complications is low for all operative techniques listed here. Demanding patients and multimedia education of patients are the reasons for a majority of operated patients in this study (97 %).

Because of its good clinical results the refixation with resorbable implants can be recommended to treat osteochondral fractures.

Between June 1990 and December 1997 116 patients with complete dislocation of the acromio-clavicular joint were treated operatively. According to the classification of Tossy and Rockwood all patients had type Tossy III or Rockwood III, IV and V of lesion. The retrospective part of the study from June 1990 to August 1994 represents 48 patients treated in 31 cases with wire-cerclage, in 14 cases with PDS-cerclage and in 3 cases with a combination of Kirschner wires and PDS. In a second group between September 1994 and 1997 68 patients were treated operatively with a special hook-plate, called Balser-plate, combined with suture of the corakoclavicular ligaments, the articular capsule and the intraarticular discuss. In the first group there was a postoperative immobilisation of the injured shoulder for 2,3 weeks necessary; in comparison to non immobilisation at the Balser-plate group. The range of motion in the Balser-plate group was free up to 90 degrees abduction. The removal of implants was performed in both groups after approximately 3 month. Postoperative complications were 8 reluxations at the acromio-clavicular joint and 10 superficial infects at the Non-Balser group and 4 superficial infects and 2 subcutaneous haematoma in the Balser group. We saw no reluxation in the Balser group. We examined 30 of 48 patients of the Non Balser group after average 50.1 month and 57 of 68 patients of the Balser group after 24.6 month. We compared the functional result, a questionnaire and the ultrasound examination of the acromio-clavicular joint with and without 10 kg weight bearing of the arm. 87.7% of the Balser patients and 67.7% of the Non-Balser-patients had free movement of the injured shoulder. Another 14.2% and 11.4% of the Balser group complained on shoulder pain with weight bearing and extreme moval in comparison to 17.4% of the Non-Balser group. At ultrasound examination comparing the injured to the non injured arm with and without 10 kg weight bearing there was a clavicula-elevation of 0.3 mm and 0.6 mm at Balser-patients and 3.0 mm and 2.5 mm at Non-Balser-patients for the injured side. In normal position the acromio-clavicular width was physiological in 50.2% of Balser patients in comparison to 36.6% of Non-Balser-patients. Under weight bearing the acromio-clavicular width increases in both groups. 63.2% of the Balser-group patients are satisfied with the result of operation, but only 43.3% of the other group (p < 0.05). Completely dissatisfied were 20% of the Non-Balser group, particularly because of the bad cosmetic result (40%).

Thirty-five patients were prospectively examined on average 5.9 and 11.1 months after reconstruction of the anterior cruciate ligament. Eighteen patients were treated postoperatively with a regular physiotherapy (PT) program 2-3 times per week for 30 min, 17 patients with a special, extended, and supervised rehabilitation program 3-5 times per week for 2.5 h. Criteria for exclusion from this study were previous operation or fractures of the affected knee. The bases for the evaluation of the clinical results were the clinical examination, the Lysholm and Tegner scores, KT 1000, angular reproducibility according to Barrett (proprioception), and the figure-of-eight hop test. It appeared that patients treated with extended ambulatory physiotherapy (EAP) gained a significantly higher degree of functionality in the Lysholm score after 5.9 months (p < 0.02) and the Tegner score after 11.1 months (p < 0.05) than patients treated with regular physiotherapy. Patients treated with EAP also displayed better results in the proprioceptive capability test with an angular deviation of 5.8 degrees after 5.9 months compared to 11 degrees in patients receiving regular PT. After 11.1 months, there were no differences in proprioceptive capability between the two groups. Although the EAP patients were faster in the figure-of-eight hop test (0.39 s difference compared to 0.58 s in the PT patients), the results were not statistically significant. In KT 1000 ventral tibial instability was on average 21% lower in the PT patients than in the EAP patients. After 11.1 months, both groups exhibited the same median value of 3 mm. Furthermore, EAP patients were able to return to work after 36.7 days on average, a 35% shorter period than in the case of PT patients (55 days), also of statistical significance (p < 0.02). To conclude, the primarily higher costs of this intensive rehabilitation program are justified by the better functional outcome linked with an earlier return to work.