Reiner Labitzke, Manual of Cable Osteosyntheses

Reiner Labitzke, Manual of Cable Osteosyntheses Springer-Verlag Berlin Heidelberg GmbH Reiner Labitzke Manual of Cable Osteosyntheses History, Technical Basis, Biomechanics of the Tension Band Principle, and Instructions for Operation

With contributions by A.J. Weiland, New York, K.-P. Schmit-Neuerburg, Essen Frei Otto, Stuttgart, A. Richter, Darmstadt D.M. DaU, Hermanus, SA, and A. Miles, Bath, UK

With 156 Figures in 400 Parts

Springer Univ.-Prof. Dr. med. habil. Reiner Labitzke Chair of Surgery of Private University of Witten/Herdecke Director of the Clinic for general surgery and traumatology of UWH at Evangeli• sches Krankenhaus, D-58239 Schwerte, Germany Studies ofhuman medicine at Humboldt-University and Free University Berlin and University of Vienna. Specialist for visceral surgery and traumatology. Fields of sci• entific work in traumatology: Biomechanics; Development of methods of operations and implants, e.g. elastic rib clamps for the flail-chest stabilisation (1976); the cable osteosynthesis system (1978) for tension bandings and related operations; the Endo• Helix (1989), an atraumatic screwed-in intramedullary stabilisator for biologica! osteosyntheses of humerus and childlike fractures of tubular bones.

ISBN 978-3-642-63059-0

Cataloging-in-Publication Data applied for Die Deutsche Bibliothek - CIP-Einheitsaufnahme Labitzke, Reiner : Manual of cable osteosyntheses / R. Labitzke. - Berlin; Heidelberg ; New York; Barcelona ; Hong Kong ; London ; Milan ; Paris; Singapore; Tokyo: Springer, 2000 ISBN 978-3-642-63059-0 ISBN 978-3-642-57167-1 (eBook) DOI 10.1007/978-3-642-57167-1 This work is subject ta copyright. AII rights are reserved, whether the whole ar part of the material is concerned, specifically the rights of translation, reprinting, reuse of illus• trations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Viola• tions are liable for prosecution under the German Copyright Law.

The use of general descriptive names, registered names, trademarks, etc. in this publi• cation 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. Product liability: The publishers cannot guarantee the accuracy of any information about the application of operative techniques and medications contained in this book. In every individual case the user must check such information by consulting the rele• vant literature. Cover design: E. Kirchner, D-69121 Heidelberg Typesetting: FotoSatz Pfeifer GmbH, D-82166 Grăfelfing Printed on acid-free paper - SPIN: 10718532 24/3135 - 5 4 3210 This book is dedicated to all those who step by step helped in the creation, development and application of cables with their imagination, vision and drive and who in many cases have remained anonymous, as well as to Netti, Tini, Nina and Niki Foreword

Professor Reiner Labitzke has authored a manual which focuses on the applica• tion of cable osteosyntheses. This technique is an integral part of the orthopae• dic and trauma surgeon's armamentarium for the treatment of fractures and non-unions. The manual describes osteosynthesis techniques which can be performed with cables after an introduction which includes a brief history of wires and ca• bles in medicine. Biomechanical data comparing tensile strengths, cerclage wire and wire cables provide a scientific basis for the use of this technique. The main section of the text describes the application of cables in the treat• ment of patella and olecranon fractures, in addition to its use in ankle joint and pilon fractures. This technique has also been used by the authors for the treat• ment of acetabular fractures and in performing osteotomies at the knee level. The manual is well illustrated and contains explanatory illustrations and photographs for each of the techniques described. For orthopaedists and trau• ma surgeons not familiar with the many applications of cable osteosyntheses, this text will be a welcome addition to their library. Andrew]. Weiland, MD, Professor of Orthopaedic and Plastic Surgery at Cornell University Medical College, Attending Orthopaedic Surgeon, Hospital for Special Surgery, New York, NY, USA Foreword-

Reiner Labitzke had completed his surgical training at the time he applied for the vacant position of a senior registrar at the Department of Trauma Surgery in March 1976, 1 year after I had been elected chairman of the Traumatology De• partment and Director of the University Clinic in Essen. Being an "AO clinic" we followed strictly the AO philosophy with regard to clinical application of the newly developed operative methods for fracture fixation as well as to basic re• search and scientific analysis of fracture healing and bone remodeling under modified biomechanical conditions. While interviewing Reiner Labitzke I was attracted by his enthusiastic dedi• cation to biomechanical research projects. His constructive criticism of the clas• sic tension band technique of fracture fIxation had led him already to a new con• cept of bipolar compression by lateral tension banding. Disappointed by a high rate of instability and delayed union of olecranon fractures treated with the AO technique of placing the prestressed wire furthest from the load axis, we changed to Labitzke's technique of bilateral cable tension banding, which proved to be the perfect solution to our instability problems. During the following years, from 1976 -1980, Reiner Labitzke successfully studied the fields of biomechanics and metallurgy. Besides his daily work as a surgeon, his valuable conceptional input was rightly felt to merit recognition. He developed a new method of plate stabilization of flail chest injuries, intro• duced a "sleeve-rope closure" of median sternotomy in open heart surgery, modified bone instruments and implants in accordance with biomechanical re• sults from the basic laboratory, and evaluated the methods developed by careful clinical evaluation of the patients during their initial treatment and follow up. The "Manual of Cable Osteosyntheses" is an abstract of his biomechanical re• search and a comprehensive report of the remarkable clinical results he achieved within 20 years of operative fracture fixation. It can be recommended to surgeons specialized in trauma and orthopedic surgery, for their routine work and as advice in special cases. Univ.-Prof (em.) Dr. med. K.-P. Schmit-Neuerburg, Essen ------Foreword- -

I find this book by Reiner Labitzke on the use of steel cables to repair bone de• fects fascinating because it shows how the excellent options for using steel ca• bles in the field of technology can be implemented in medicine. It is about na• ture and human beings and the use of technical devices in life. It says in the Bible: "And God saw everything that he had made, and, behold, it was very good;' But is nature always good and always effective? Is bone good? It breaks if it is subjected to extreme overloading. It is not ideal. No one would ever design the shock strut of an aeroplane or a bicycle frame using artificial bone. Human beings cannot exist without nature, both animate and inanimate, and nature is therefore good, at least for human beings. However, we can also ask the opposite question, one that is quite rightly a central issue in our day and age: Are human beings good for nature? We invent houses, weapons, vehicles for use on land, in the air and in space without any relation to nature. We are afraid of the forces of nature. If nature is very good, why not imitate it? It is now very popular to say that we should take nature as our guide. Of course, we may imitate nature, but it requires skill. "Our new design was inspired by nature" is something you often read, or even "Frei Otto studied spider webs and was thus able to build his wide-span roofs with thin nets of steel cables, such as the roof for the Olympic Stadium in Munich;' Such statements are frequently made in books about bionics, but they are usually wrong. Spider webs did not serve as a model, not even subconsciously. My roofs were built using the particular features of steel wire cables and the existing tech• niques used to construct cranes and suspension bridges, combined with the age-old production methods for tents and sails, and improved on the basis of new theoretical models of how to minimise the amount of material and energy required. In the 1960S, when the first extremely thin, very wide-span nets hung in the air, the biologists involved in spider research recognised the similarity. Zoolo• gists, architects, engineers and cable specialists compared ropes, knots, founda• tions and anchor points and did in fact discover real similarities between the webs spun by spiders and the nets constructed by architects. Both bear loads, are elastic, relatively fixed, are made of very thin, high -tensile, flexible elements and have a similar shape. However, spiders spin their webs to catch insects as they always have done ac• cording to genetically anchored construction plans, while we continue to im• prove the construction oflarge net roofs to protect us against the rain and cold using the knowledge obtained in technology and architecture. Little has changed in reality, but all those involved have learned from each other. The zo- X Foreword Frei Otto

ologists have increased their understanding of human technology, while the ar• chitects have increased their understanding of the constructions found in na• ture. That is the first step towards regarding nature as a whole. Bone is a part of nature, a part of human beings. It is neither very good nor bad. It has the outstanding feature that it can adapt by internal modification and, to a limited extent, is able to repair itself. In the case of complicated frac• tures, the help given by the treating physician is good, sometimes even very good, and often saves lives. Instead of using the thick bonding wires that have commonly been used up to now, Reiner Labitzke repairs bone using fine, thin cables, high-performance products from the field of high-grade steel/fine-wire technology - at long last, a method that is heading in the right direction. The bonding wires that have been used up to now are too stiff and take all the load instead of forming an elastic, mechanical unit with the bone. It is a logical method that has been thought through very well and is based on knowledge at the exact border between technology and biology, i.e. wire cable constructions that are subject to tensile stress, but also at the limits of our bio• logical understanding of bone. Bones are bundles of fibres and three-dimen• sional nets containing gaps filled with hard substance. There is no equivalent to bone in the field of technology, although there are certain similarities to timber• frame construction, pre-stressed concrete and construction using fibre• strengthened plastics. By introducing steel cables into medicine, I believe that Reiner Labitzke has opened up the way for the surgical treatment of fractures to be further devel• oped, also in terms of the materials used. I can also imagine that instead of indi• vidual cables, for example, whole networks may be used. Extremely soft or par• ticularly hard types of steel or elastic wires twisted like spirals that extend and stretch, forming a transition to screws, can be used as required. I can also imag• ine other materials being used that either remain in the bone or can be removed, and material that, although initially required to be very strong, is degradable without leaving any residue. The present level of technological knowledge is high and developments are rapid. Knowledge about bone has also grown in the past decade. However, bone remains the same. It cannot be improved. It merely changes in the course of an organism's life from being soft to being hard, it alters its shape, and it may break and grow together again. But do we know how its shape and fine structure arise, how the fibres really bear loads in conjunction with the hard substance and what the significance of the internal pressure is, for example? In the course of our work on living constructions, we discovered that, al• though the hard substance of bone primarily reduces deformation under load, its weight-bearing capacity depends above all on the network of high-tensile connective tissue fibres that organise growth, determine the shape and also, in conjunction with the internal pressure, reshape, repair and even continually im• prove in relation to the load. It is the structure of the connective tissue fibres and the adapted internal pressure that are behind the secret of how the shape and adjusted weight-bear• ing capacity of bone arise. The fine, load-dependent deformations that continu• ally occur in the hard substance stored between the connective tissue also ap• parently allow the fine structure to adapt to altered load. This would appear to be a very particular role of the hard substance. Great progress could be achieved in bone surgery if the self-repair mecha- Foreword Frei Otto XI nisms could be stimulated not only to heal fractures, but also to restore entire bones. There are still a number of open questions for the generations to come and a range of details that doctors, architects and engineers ought to discuss and work on together in the near future. Unfortunately, this is something that has only oc• curred in exceptional cases up to now. For me, the introduction of elastic steel cable constructions not only marks the beginning of a considerable improvement in surgical techniques, it also re• flects our improved understanding of the weight -bearing behaviour of bone. I hope that Reiner Labitzke is able to make good progress in further develop• ing the surgical treatment of bones, and I hope that this book is very successful. It is, I believe, a particular milestone on a long road. Univ.-Prof (em.) Dr.-Ing. Dr. h.c.mult. Frei Otto Director of Institute for Leightweight Structures (II) University of Stuttgart, Germany Foreword A. Richter XIII technique of employing rigid cerclage wires in 1978, I already wondered why this had not been done before. The former principle has so many more advantages - not least of guaranteeing much higher stability - than the latter, and it is hoped that something that is so obvious in physics and engineering will also become accepted in medicine. Therefore, may Professor Labitzke's clearly structured and intelligently and, also from the point of view of a physicist, didactically well• written book pave the way to acceptance of this technique, become widely dis• tributed, and soon be a standard text in modern osteosynthesis.

Professor Dr. rer.nat. Dr. h.c. multo Achim Richter Director of the Nuclear Physics Institute Technical University Darmstadt, Germany Foreword

In the late 1960'S, one of us was trained by Sir John Charnley in the philosophy and practice of total hip arthroplasty. The Charnley method of low friction art• hroplasty was designed with a small 22,25 mm head and, as a result, convention• al approaches had a high incidence of dislocation. For this reason John Charnley insisted on the trochanteric osteotomy approach to the hip joint as an integral part of the technique of low friction arthroplasty. The advantages of this ap• proach were, increased exposure, and increased stability of the prosthetic joint post-operatively, due to the fact that the abductor muscles could be tensioned by the distal advancement of the greater trochanter. The major disadvantage of this approach was due to a relatively high inci• dence of trochanteric detachment. Fixation techniques at that time involved the use of monofilament stainless steel wire. It was this single clinical problem which led us to the realization of the advantages of multifilament cables over monofilament wires. In this excellent manual of cable osteosyntheses, Professor Labitzke has kindly referred to our first clinical results which were published in the Journal of Bone and Joint Surgery in 1983. At more or less the same time as we were developing enthusiasm and excite• ment about the use of multifilament cables in orthopaedic surgery, Professor Labitzke was doing exactly the same thing on another continent - as is so often the case in science. In the practice of orthopaedic surgery and traumatology it is always exciting to find a colleague with directly similar interests and views. Professor Labitzke has indeed provided an authentic manual covering the historical, experimental and clinical aspects of the use of multifilament cables in orthopaedic surgery and traumatology. His in-depth bibliography, especially in the historical section, and the wealth of information that he has presented on the subject is highly commendable. The strength issues of monofilament wire are compared with the superior mechanical properties of multifilament cable. In this context, we could add our own realization of the importance of the supe• rior fatigue strength of multifilament cable compared to monofilament wire. He goes on to present an in-depth analysis of tension banding and convincing argu• ments in favour ofbi-lateral tension banding with cables. The clinical sections discuss in depth the techniques that he has developed for treatment of fractures of the patella, olecranon process, medial malleolus, and osseous prominences including the greater trochanter, acetabulum and that of the pelvic ring. In addi• tion he has developed techniques using multifilament cables for valgus osteoto• my of the proximal tibia, ankle arthrodesis and certain soft tissue injuries. There is also a brief section on the treatment of shattering of the femur shaft fol• lowing total endoprosthesis insertion. The Dall-Miles cable system, which is similar in principle to the system developed by Professor Labitzke, has been used in many of these applications, but has probably been used most extensively Foreword D. M. DalilA. W. Miles XV in revision total hip arthroplasty - especially for allograft fixation in deficient femoral bone stock, periprosthetic fractures of the femur and re-attachment of the greater trochanter. The system has been used extensively in North America and world-wide with very gratifying clinical results. For this reason, we are particularly delighted to find that our successful expe• rience with multifilament cable is shared by Professor Labitzke, not only in principle, but also in his clinical results. We are in full agreement with the author when he says "Now, however, the time has come for wire to be replaced ... the future, indeed, belongs to cables".

Desmond M. Dall, M. Ch(Orth), F.R.C.S, Emeritus Professor of Clinical Orthopaedic Surgery University of Southern California, Los Angeles, Calif, U.S.A. Anthony W. Miles MSc(Eng), Reader in Biomechanics University of Bath, Bath, England Preface

Tension bandings are a principle with which technology has been able to tame great forces. Nobody would even dream of using rigid wire, a fact that one would readily acknowledge upon examining suspension bridges that today span many of the world's largest rivers. This principle, transferred to the comparatively small forces existent in bone surgery, has always fascinated me. It is for this rea• son that I have never really understood why one of the best tools that engineers have at their disposal should not also be put to good use within the operating theatre. This treatise deals to a large extent with the biomechanics of the tension band. Here it was necessary - with the aid of engineering science - to newly de• fine the theoretical concept of operative tension banding, which to date has raised a few erroneous assumptions within the medical community. Consequently, the necessity arose to adapt wire cables for operative use and to develop a practical system with appropriate tools. Twenty years of experience have shown that this attempt indeed has been successful. Since 1978, I have been using supple wire cables designed in accordance with my own specifications for osteosyntheses, a process which throughout the past decades has usually been reserved for cerclage wire. In stark contrast to rigid wire, wire cables have many advantages which are reflected in a broadening of indications as well as in an improvement of results. Many colleagues, who have been using this method for almost as long as I have, and indeed several large companies have come to value these advantages. Despite a patent protection different types of cables, ranging in price, have been steadily entering the German as well as the international market, a fact that will undoubtedly be beneficial to the success of the wire cable. With this book, richly illustrated with 400 single descriptions and 5 dia• grams, I would like to pass on my knowledge. It seemed inappropriate to publish these findings at an earlier stage, simply because the euphoria that is often pre• sent when implementing a new idea should eventually give way to a certain level of objectivity. I set to work with realistic expectations, and a conviction that is possibly best summed up by Max Planck in his "Wissenschaftliche Selbstbiographie" of 1955 - a scientific autobiography: ''A new scientific truth does not usually establish it• self in a way that its opponents are convinced and declare themselves converted, but rather due to the fact that they gradually demise, thus allowing the new gen• eration to grow up with the truth?' This book is designed to appeal not only to the experienced surgeon but also to younger doctors with a questing attitude to medical life. It offers an overview of the historical and technical facts. The reader is also given the opportunity to thoroughly study the principles of tension banding as well as the ideal material to realise it - wire cables. Preface XVII

Despite the scientific proof of the theories underlying the following explana• tions it would be inappropriate to dismiss possible reservations or criticisms. Within this respect, allow me to quote from Theodor Billroth's preface, pub• lished in 1876 in "Uber das Lehren und Lemen" (On Teaching and Learning): "One might choose to judge me, but one will not succeed in diminishing the val• ue of my work, which is characterised by the accurate compilation of pertinent facts, many of which will be as new to my colleagues as they were to me upon stumbling across them" [273].

I extend my thanks to all those who have accompanied and supported this work - for their consideration, assistance and patience. To my wife and children, who in the last years saw me spending more time in my study than anywhere else. To my hospital colleagues, especially to Dr. Hahn for supporting me when it came to studying databases, retrieving and sorting X-ray bags and outpatient clinic notes, as well as the call-up of patients. My friends T. Redelings, Dr. G. Conrad and Dr. M. Mielsch gave me interesting stimuli during the writing of the book. My thanks also go to Mrs. B. Klett and Mrs. H. Bongert for dealing with the pa• perwork; St.Clair Bull Consulting translated the text into English. My daughter, Mrs. N. Labitzke, was a great help in proofreading and in drawing up the subject index. Mr. Schilling from the Zentralbibliothek fur Medizin in Cologne helped me in tracking down long-lost original works. Mr. Bowe, the former head of the workshop of the Institut fiir Werkstoftkunde at the Ruhr University Bochum, performed trials on the stability of wires and cables as well as operative proce• dures. This work was updated thanks to Mr. Griinewald and Dr. Partz of the board of directors of the Stahlwerk Ergste Westig GmbH in Schwerte. Mr. Kon• necke of Feinseilerei Engelmann in Hanover promoted the development of wire cables from the start and assisted me in word and deed. Mr. Bahmiiller, Team Design Schwerte, took the photographs of the implants and the tools and Mrs. B. Rosigkeit provided the sketches. I would also like to thank Mr. Runkel, chief engineer of the Rheinische Brilckenbauamt, for the graphic demonstrations and many technical details about suspension bridges. I also thank Prof. Dr. Schmit• Neuerburg of the Klinikum der GHS Essen, my former surgical chief, for his much appreciated medical input, and Prof. Dr. rer. nat. Dr. h.c. multo Richter of the Technische Universitiit Darmstadt for the technical foreword. My gratitude also goes to Mr. Dall, M.D., South Africa, and Mr. Miles, Engineer, from Bath, GB - who were the first using cables after my own publications - as well as to Profes• sor Weiland, M.D., New York and past President of the American Orthopaedic Association for their contributions. My thank also goes to Prof. Dr.-Ing. Dr. h.c. multo Otto, the former director of the Institute for Leightweight Structures of the University of Stuttgart, who applies cables for his visionary architectural con• structions, and who has emphasized "how the excellent options for using steel cables in the field of technology can be implemented in medicine". Not least, I thank Mrs. G. SchrOder and Mrs. M. Himberger from Springer- Verlag for their support. Univ.-Prof. Dr. Reiner Labitzke Schwerte, Germany Contents

Introduction ......

2 Brief History of Wires and Cables in Medicine and Technology 2.1 Conventional Binding Wire...... 4 2.1.1 Bone Suture: The Original Form of Osteosynthesis...... 4 2.1.2 Chronology of Osteosyntheses ...... 6 2.1.3 Experiences with Cerclage Wire: A Critique...... 6 2.2 Wire Cables - State-of-the-Art Solution ...... 12 2.2.1 A Brief Introduction, Including Valuable Technical Data...... 12 2.2.2 Principle of Cable Osteosyntheses ...... 19 2.2.3 The Osteosynthesis Set ...... 19 2.2.3.1 Wire Cables...... 19 2.2.3.2 Crimps...... 20 2.2.3.3 PE Sleeves ...... 22 2.2.3-4 Instruments...... 23

3 Cerclage Wire and Wire Cables: A Comparison 3.1 Performance and Testing ...... 26 3. 2 Results ...... 27 3. 2.1 Tensile Strength of Cerclage Wire and Wire Cables ...... 27 3. 2.2 Tensile Strength of Twists and Cable-Crimp Connections ...... 28 302·3 Tensile Strength of Bent Cerclage Wire ...... 31 3-2-4 Evaluation of the Results ...... 32 3.2.4.1 Cerclage Wire ...... 32 3.2.4.2 Wire Cables ...... 32 3.2.5 References in the Literature ...... 33

4 Wire Cables in Everyday Hospital Life 4. 1 Introduction ...... 34 4·2 Technical Instructions for Operations ...... 35 4·2.1 Tension Band Principle ...... 35 4. 2 .2 Cerclage ...... 36 4. 2 .3 Sleeve-Cable Combinations ...... 37 4. 2 .4 Stretching and Crimping ...... 38 4.2 .5 The Final Steps ...... 39 4. 2 .6 Errors and Risks ...... 40 4·3 The Mechanics of Bone Healing ...... 43 4·4 Biomechanic of Tension Band Principle ...... 44 4-4.1 Tension Banding as a Technical and Osteosynthetic Principle ... . 44 4·5 Patella Fracture ...... 51 XX Contents

4.5. 1 Historical Procedures ...... 52 4.5.1.1 Closed Adjustment ...... 53 4·5·1.2 Open Bone Suture ...... 54 4·5·1.3 Tension Banding ...... 56 4.5. 2 Weber's Patella Tension Band and its Biomechanical Analysis ... . 60 4·5·3 Bilateral Cable Tension Band and its Biomechanical Analysis ... . 66 4.6 Olecranon Fracture ...... 77 4.6.1 Historical Procedures ...... 78 4·6.2 Weber's Olecranon Tension Band and its Biomechanical Analysis 80 4.6.3 Bilateral Cable Tension Band for Olecranon and Proximal Ulna Fractures ...... 85 4·7 Ankle Joint and Pilon Fractures ...... 93 4·7·1 Cable Tension Banding on the Medial Malleolus ...... 94 4. 8 Osseous Prominences ...... 102 4.8.1 Trochanter Major Femoris...... 102 4.8.1.1 Trochanter Cable Tension Banding ...... 105 4.8.2 Proximal Humerus and Tuberculum Majus ...... 109 4·8.2.1 Cable Tension Banding on the Head of the Humerus and Tuberculum...... 110 4.8.3 Distal Humerus Fractures...... 115 4.8.3.1 Cable Tension Banding Shown on Epicondylus Ulnaris Avulsion 115 4.8-4 Avulsion Fracture at the Base of the Fifth Metatarsal ...... 117 4.9 Compression Cable Osteosynthesis ...... 119 4.9.1 Acetabulum Fractures and Dorsal Socket Avulsion Fracture ..... 119 4.9.2 Corrective Osteotomy in the Knee Joint Region ...... 122 4·9·2.1 Cable Osteosynthesis to Compress Valgus Tibial Head Adjustment Osteotomy ...... 122 4·10 Cable Arthrodeses ...... 126 4·10.1 Cable Arthrodesis of the Upper Ankle Joint ...... 127 4·10.2 Pirogoff Amputation with Tibio-Calcaneal Cable Arthrodesis ... . 131 4·11 Cable Cerclages ...... 135 4·11.1 Shattering of Femur Shaft Following Total Endoprosthesis ...... 135 4·12 Sleeve-Cable Banding of Unstable Pelvic Ring Injuries ...... 138 4·13 Sleeve-Cable Osteosynthesis of Longitudinal Sternotomy ...... 146 4·14 Soft Tissue Trauma - Temporary Protection of Ligament Sutures Using a Cable ...... Rupture of the Ligamentum Patellae, Quadriceps, and Achilles Tendon ...... 4.14.1.1 Ligamentum Patellae ...... 148 4.14.1.2 Quadriceps Tendon ...... 150 4.14.1.3 Achilles Tendon ...... 152 4.14.1.4 Ligamentum Patellae...... 152 4.14.1.5 Quadriceps Tendon ...... 153 4.14.1.6 Achilles Tendon ...... 153 4.14.2 Rupture of the Anterior Cruciate Ligament: Treatment According to Weigand ...... 153 4.15 Special Indications...... 155 5 Review and Outlook...... 170 References ...... 171 Subject Index...... 183