The modified Bristow procedure for recurrent dislocation of the shoulder.

A review of fifty-one cases of the modified Bristow procedure for recurrent anterior shoulder instability is presented. The results were favorable. The redislocation rate was 2% with few complications. The average limitation of motion was 11 degrees of external rotation. Athletic individuals with involvement of the dominant shoulder were not capable of returning to high performance levels of overhead sports activity (particularly throwing) after the operation.

The results of operative treatment of osteochondritis dissecans of the patella.

The course of osteochondritis dissecans (OCD) of the patella and the results of operative treatment are analyzed retrospectively in a review of 31 operatively treated cases in 25 patients. Followup was obtained for 21 cases, with an average of 73 months (range, 15 months to 20 years). These 25 patients were predominantly males, and averaged 18 years of age at the time of surgery. A history of trauma was associated with the lesion in 38% of the cases, and the lesion was bilateral in one out of four patients. The most common presenting complaints were subpatellar pain and swelling. The most common initial physical findings were patellofemoral crepitus and joint effusion. Forty-four operations were performed on 31 knees. The most commonly performed procedures were curettage of the patella and removal of loose bodies, in combination or as part of another procedure. A new patellofemoral rating scale was used to evaluate results. Thirty-eight percent of the knees had a good or excellent result, while 62% had a fair or poor result. Persistent pain with restricted function and residual patellofemoral crepitus were common findings. In general, the patients who come to surgery for OCD of the patella have a guarded prognosis for full recovery of knee function.

Multiphasic view of medial meniscectomy.

In a retrospective study, the records of a group of 816 patients who had tears of the medial meniscus alone were selected for review from a total of 6,000 records of patients who had had knee surgery (1966 to 1976). According to the operative reports, these 816 patients had no other structural or pathologic findings at the time of medical meniscectomy. In an average of 2.0 years after initial surgery to the knee, 210 patients required subsequent surgical procedures for progressive meniscal pathology (38), articular cartilage damage (64), or ligamentous instability (108). The recognition of the possiblility for future surgery after medial meniscectomy is an important finding which must be acknowledged by the treating physician and to the patient. The evidence from the review suggests that others should review series of patients with tears of the medial meniscus and should attempt to gain understanding of the basic pathologic processes.

Arthroscopy of the knee under general anesthesia: an aid to the determination of ligamentous instability.

During a 34-month period (March 1976 through December 1978), 790 patients underwent arthroscopic examination of the knee under general anesthesia. Preoperative assessment of ligementous instability was compared with the ligamentous examination while under general anesthesia. Eight percent of the patients with no preoperative instability first demonstrated ligamentous instability under general anesthesia. Thirty-six percent of the patients with preoperative instability and 27% of the patients with previous surgery had either an increased grade or additional component of instability found when examined under general anesthesia. Information gained from arthroscopy without a comprehensive ligament examination under anesthesia may result in an incomplete diagnosis and ineffective treatment. Patients at high risk include those with acute injuries, preoperative instability, or previous surgery.

Acute posterior cruciate ligament injuries.

One hundred and two posterior cruciate ligament injuries were reviewed (43 chronic and 59 acute repairs). The 59 acute repairs were profiled as to cause and site of injury, associated ligamentous damage, clinical examination, patient position at surgery, and reoperation rate. Twenty-two patients were followed up. Motor vehicle accidents and athletics were the usual causes of injury. In the 59 acute repairs, the posterior cruciate avulsion site was femoral in 21, midsubstance in 13, and tibial in 25. The high incidence of associated injuries included medial collateral ligament tears, capsular damage, lateral knee component damage, and anterior cruciate ligament ruptures. Thirteen of 59, believed to have isolated tears, had surgery in the prone position. Twelve were subsequently reoperated. Eight of 12 reoperations were done prone initially for an "isolated" tear. Our acute knees with poor results all had the most supposed "isolated" and midsubstance tears, and the most popliteal surgery. The posterior cruciate ligament tear is due to major violence with associated ligament injuries and has no single universal physical sign. Arthroscopy and examination under anesthesia are recommended to prevent the missed diagnosis (chronic case) or to clarify a suspected "isolated" tear prior to prone popliteal surgery.

Intraarticular substitution for anterior cruciate insufficiency. A clinical comparison between patellar tendon and meniscus.

Forty two patients with functionally incapacitating 2+ or 3+ anterior instability underwent anterior cruciate ligament substitution using a meniscus (25 patients) or central third of the patellar tendon (17 patients). Subjective and objective evaluations were personally performed on all patients with an average followup of 15 months. Seventy-nine percent of the patients were objectively graded successful. Objective results were primarily based on the surgeon's technical ability to correct completely all components of anterior instability at the time of surgery. Subjective results were multifactorial and were correlated primarily with patient expectations, the presence or absence of continued buckling and the ability to return to recreational activities. The only observed difference between the two types of cruciate substitutions was the average loss of 6 degrees of flexion in the central third of the patellar tendon group. Both the patellar tendon and meniscus clinically appeared to be successful intraarticular cruciate substitutes which can predictably correct moderate to severe anterior instability of the knee in a high percentage of patients.

The patient's view of the pes anserinus transfer operation for rotatory instability of the knee.

A review of 82 patients was performed to ascertain their subjective evaluations of the pes anserinus transfer procedure for rotatory instability of the knee. Analysis demonstrated a slow improvement in symptoms which occurred over a 12-month period. At that time, 62% of the patients had regained 90% of their preinjury confidence in knee stability.

The patellofemoral joint and its implications in the rehabilitation of the knee.

The normal mechanics of patellar motion lead to an eventual age-dependent degeneration of the patellofemoral joint in the majority of persons. This review explores the relationships between normal patellar mechanics, patellofemoral joint disease, and findings of quadriceps femoris muscle-function studies. Implications of these relationships are then discussed with regard to the rehabilitation of all patients.

Operative arthroscopy for the treatment of problems of the medial compartment of the knee.

This study reports early results in patients who underwent operative arthroscopy involving the medial compartment of the knee. The patients were selected because they had meniscus and articular lesions associated with middle age. Visualization of defects was via video camera and television screen. Triangulation was the main technique used for operative arthroscopy. Results were classified as Good (67%) Fair (20%), or Poor (13%). Marked arthritis involving the medial compartment was felt to account for the final result in nearly all of the patients in the Fair and Poor groups. The report concludes that operative arthroscopy is generally well tolerated. In this group of patients the results depended on the amount of arthritis. The greater the amount of arthritis in the knee, the worse the result. The results in these middle-aged patients are comparable with those achieved by formal arthrotomy in similar groups.

Reoperation following patellectomy for chondromalacia.

When primary patellectomy is performed for chondromalacia of the patella and subsequent surgery is required, this indicates failure of the initial procedure. A review of 51 patients having patellectomy for chondromalacia revealed a failure rate of 39% as evidenced by reoperation. Analysis of these cases showed continued extensor mechanism malalignment and/or continued degeneration of the distal femur or soft tissue as the reason for additional surgery. We believe that a careful preand intraoperative evaluation of the extensor mechanism kinematics and articular cartilage status of the distal femur is essential in lowering the failure rate of patellectomy for chondromalacia.

The use of electrosurgery for arthroscopic subcutaneous lateral release.

49 patients underwent subcutaneous lateral retinacular release for pa tell of emo ral malalignment syndromes by a new technique utilizing the arthroscope and electrocautery. In this technique, the tight lateral patellofemoral ligament and lateral retinaculum are transected with the electrocautery under direct arthroscopic visualization. It is possible to directly observe the progress and completeness of the release, and to cauterize any bleeding vessels sequentially as they are transected. The procedure is simple, quick, and has a low 3.8% rate of complication. In the postoperative period pain is minimal, requiring only non-narcotic medication. Patient hospital stay is reduced, with dismissal usually one day after surgery. Knee motion as well as quadriceps control are rapidly recovered. One week after surgery 90% of patients gained 90° or more of flexion, and the remaining patients achieved this by the second week after surgery.

Ligament replacements--clinical evaluation.

Prosthetic ligament device evaluation techniques involve the following: stating the goals of the use of the prosthesis; obtaining adequate postoperative assessment by using standard clinical measurements of joint stability and performance; obtaining the patient's own evaluation of the reconstructive process; and periodically insuring that there is retention of the initial benefits obtained throughout the recovery period.

Incidental metastatic mammary carcinoma in a total knee arthroplasty patient.

Incidental metastatic breast carcinoma was discovered by histologic examination in a total knee arthroplasty (TKA) patient. A 70-year-old woman was evaluated for increasing debilitating pain in the right knee. A radiograph demonstrated only degenerative changes. Degenerative changes were noted in the gross and microscopic examination of the knee specimen. The unsuspected focus of poorly differentiated adenocarcinoma was suggestive of mammary carcinoma. A mass in the right breast then was subsequently noted on reexamination. Mastectomy showed infiltrating adenocarcinoma with metastases to axillary lymph nodes, and diffuse involvement of the skeleton was demonstrated with a bone scan. This case emphasizes the importance of a meticulous history and a complete medical examination before surgery, detailed examinations of the excised knee and joint fragments by a pathologist after a TKA operation. Malignancy can be missed with only gross specimen evaluations and radiographs.

The synovial response after CO2 laser arthroscopy of the knee.

The CO2 laser is a precision surgical laser because of its high degree of absorption in soft tissue with limited lateral damage. The tissue, which absorbs the CO2 laser energy, and has a high water content, will be converted to vapor with a small residue of ash and a by-product of heat. The laser can only be effective if these by-products, i.e. vapors, heat, and carbon ash residue, are not injurious and are well tolerated by the joint. These by-products must be either reabsorbed by the synovium or remain as a nonviable substance in the joint. From April 1989 through April 1990, 40 patients underwent 43 operative arthroscopies of the knee using the Pfizer CO2 laser. All procedures were chondroplasties, synovectomies, and/or meniscectomies. All accessible CO2 carbon ash residue was removed from the joint after the procedures using an intraarticular shaver and hand rasp. Postoperatively there were no cases of hemorrhagic effusions, subcutaneous emphysema, or synovitis. Histologic examinations performed on 10 patients undergoing subsequent surgery showed no evidence of carbon ash residue or synovitis seen grossly or microscopically. The carbon ash residue is not noxious to the joint and is completely removed from the joint, presumably by the synovial response.

The Synovial shelf syndrome.

A syndrome complex mimicking a tear of the anterior horn of the medial meniscus consists of absence of effusion with negative arthrographic and arthroscopic examinations. Because of a thickened band of the medial synovial shelf this entity is termed the "medial synovial shelf syndrome."