Diagnosis of internal derangements of the knee. The role of arthroscopy.

In a prospective study of 100 patients with internal derangement of the knee, clinical diagnosis, arthrography, arthroscopy, and arthrotomy findings were compared. The clinical diagnosis was correct in seventy-two patients, correct but incomplete in ten, and incorrect in eighteen. Arthroscopy was accurate in ninety-four, influenced surgical therapy in fifty-five, and revealed unexpected disease in twenty-five patients. It was found to be critical for diagnosis in sixteen patients. Twenty-three additional patients were analyzed who underwent arthroscopy but not arthrotomy. Unnecessary operations were avoided in twenty-one of these twenty-three patients.

Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data.

Fifteen patients who had sustained a rupture of the Achilles tendon were managed non-operatively with use of a functional bracing protocol, and clinical and functional performance measures were assessed after a mean duration of follow-up of thirty-one months (range, twenty-four to forty-five months). An age and gender-matched group of fifteen subjects was assessed to provide normative data for the comparison of side-to-side differences. Numerical scores were generated on the basis of subjective responses to a questionnaire, clinical measurements of the range of motion of the ankle and the circumference of the calf, and the results of the Thompson squeeze test and a single-limb heel-rise test. A 100-point scoring system was used to categorize the outcome as excellent, good, fair, or poor. In addition, ground-reaction forces and temporal data were assessed during functional dynamic activities that included walking, a single-limb power hop, and a thirty-second single-limb heel-rise endurance test. The result was graded as excellent for three patients, good for nine, fair for two, and poor for one. An increase in passive dorsiflexion of the treated ankle was the only clinical measure that was significantly different between the groups (p = 0.02). This increase in dorsiflexion was positively correlated with vertical force output between the mid-stance and terminal-stance phases of gait (r = 0.40, p = 0.05). With the numbers available, we could detect no significant differences between the groups with regard to the kinetic or temporal variables that were measured during functional dynamic activities. Patients who generated less peak vertical force and vertical height during the single-limb power-hop test tended to have poorer clinical scores. We believe that non-operative functional bracing may prove to be a viable alternative to operative intervention or use of a plaster cast for the treatment of acute ruptures of the Achilles tendon. The goals of treatment are to prevent the musculoskeletal changes that are associated with immobilization, to reduce the time needed for rehabilitation, and to facilitate an early return to work and to preinjury activities.

Non-operative treatment of meniscal tears.

In a retrospective review of the results of 3,612 arthroscopic procedures that were performed for the treatment of an acute or a chronic meniscal lesion, with or without an associated ligamentous lesion, we identified eighty meniscal tears (in seventy-five patients) that had been assumed to be stable. Seventy were vertical longitudinal tears and ten were vertical radial tears. The seventy longitudinal tears included fifty-two lateral and eighteen medial meniscal lesions. All of the radial tears were in the lateral meniscus. Of the seventy-five patients, fifty-two had been followed for two to ten years. At the time of follow-up, only six of these fifty-two patients had needed additional intervention because of symptoms that were related to the meniscal tear. Four of them had the intervention after a sports-related traumatic extension of a stable tear, and two, because persistent symptoms were caused by the original meniscal lesion. A repeat arthroscopy was performed on thirty-two patients (twenty-six of whom had a longitudinal tear and six of whom had a radial tear), at an average of twenty-six months after the original arthroscopy. Seventeen of the twenty-six longitudinal tears had completely healed. Five of the six radial tears had no evidence of healing and one had extended. Neither ligamentous laxity nor a meniscal tear that was chronic at the time when it was discovered appeared to preclude healing of the stable longitudinal tears. No localized degenerative changes in the adjacent articular cartilage were found in association with any of the stable vertical longitudinal or radial meniscal lesions. Excluding the six patients who had had additional surgical treatment, none of the fifty-two patients who filled out a questionnaire reported that they had symptoms of a meniscal lesion, and none of the forty-two patients who were re-examined two years or more after the operation had signs of a meniscal lesion. Stable vertical longitudinal tears, which tend to occur in the peripheral vascular portions of the menisci, have great potential for healing. The tear should be left alone unless it is the only abnormality that is found and it is causing symptoms that warrant treatment. Stable radial tears, which tend to occur in the avascular inner one-third of the meniscus, have little potential for healing. Whether it is best to leave these lesions alone or to fashion an intact rim by contouring the meniscus was not established by this study.

Diagnosis of acute knee injuries with hemarthrosis.

One hundred thirteen consecutive athletes, who had sustained significant acute trauma to the knee wit; immediate disability and the early onset of hemarthrosis but who did not have demonstrable clinical laxity, were examined under anesthesia and had arthroscopy within 3 weeks of injury (the majority within 10 days). Lesions of surgical significance were found in 102 of the 113 cases (90%). Anterior cruciate ligament tears were present in 81 (72%), of which two-thirds also had associated meniscus lesions. Major meniscus tears with no associated cruciate lesions were found in 17 cases (15%), osteochondral fractures in 7 cases (6%), posterior cruciate ligament tears in 3 cases (3%), and no internal derangement in 5 cases (4%). Acute knee injuries with hemarthrosis, rather than being a contraindication to arthroscopy, are in fact one of the best indications for use of this procedure.

Magnification and high-resolution radiography in sports-related injuries.

Magnification, or high-resolution radiography, is a widely accepted technique and is currently used in angiography, mammography and pediatric chest radiographs. Small avulsion fractures of the bones of the hand and stress fractures of th tibia are examples of two areas where the fracture may not be apparent on conventional films, although in many cases magnification radiography will demonstrate the lesions. Six representative case histories are provided to illustrate the use of magnification radiography in sports-related injuries.

Athletic injuries: comparison by age, sport, and gender.

Injuries treated at the University of Rochester Section of Sports Medicine over a 7 year period were surveyed. Patients were drawn from professional, intercollegiate (Division III), high school, intramural, and unorganized athletics at the University and the surrounding community. Data on injury diagnosis was available for 4,551 cases, with data on age, gender, and sport of injury available for 3,431 of the cases. The average patient age was 21.6 years, with a peak in the 16 to 19 age group. Patients with fractures had an average age below the overall mean, while those with internal derangement of the knee, patellofemoral pain syndrome, and inflammatory injuries were significantly older than average. Males accounted for 80.3% of all injuries. For both sexes the most common areas injured were the knee and ankle, with sprains/strains the most common injuries. Injuries involving the patellofemoral articulation were significantly more frequent among females. The most common sport of injury was football, with greater than 12 times the number of injuries seen in the next most common sport.

Open meniscus repair. Technique and two to nine year results.

An average 4.6 year follow-up study has been done on 80 of 104 open meniscus repairs of unstable peripheral tears. Two of nine retears were treated in the acute stage and seven were treated in the chronic stage. Eight retears were medial, one was lateral (repair ratio, 1.5:1 medial to lateral), three occurred through the repair site, and six occurred in different areas. Retears occurred in 1 of 26 isolated repairs, 2 of 38 repairs done with an ACL stabilization procedure, and 6 of 16 repairs done in ACL deficient knees that were not stabilized. Standing radiographs revealed normal compartments in 40 of 41 repairs.

Chondromalacia patellae in athletes. Clinical presentation and conservative management.

A comprehensive conservative management program for chondromalacia patella in athletes has been presented. The clinical manifestations and the efficacy of conservative treatment have been documented in the prospective study of 100 consecutive athletes. The over-all success rate was 82%, and 18% were considered to be failures of conservative treatment. Only 8 of these 100 athletes have required surgical treatment. It was concluded that this type of conservative management is effective in the majority of athletes with symptomatic patellofemoral syndromes, and that surgical treatment should be necessary for only the relative few who fail to respond to an adequate trial of conservative treatment.

The surgical treatment of arthrofibrosis of the knee.

Sixty-one lysis of adhesion procedures were performed for arthrofibrosis of the knee between 1981 and 1990. In 43 cases (37 patients) the etiology was prior knee ligament surgery. Ten cases had sustained fractures about the knee and eight had miscellaneous etiologies. Six patients required a second lysis of adhesion procedure. A retrospective analysis of the 43 ligament patients was undertaken to evaluate the results of surgical treatment. All 43 cases were available for followup at an average of 3.6 years. Surgical indications included flexion or extension deficits of > or = 10 degrees or when motion failed to improve despite 2 months of intense therapy. Follow-up assessment included clinical and radiographic evaluation. Flexion improved from 83% to 97% of the contralateral side. Extension deficits improved from 14 degrees to 3 degrees. Only 23 of 37 patients (62%) achieved satisfactory functional results. Radiographic evidence of degenerative changes, soft tissue calcification, and patella infera was found in 89%, 51%, and 9% of the patients, respectively. Patients requiring surgical treatment for arthrofibrosis after knee ligament surgery achieved excellent motion gains, but functional outcome scores were compromised and radiographic findings were concerning. Patients with the localized anterior intraarticular variant or those undergoing lysis of adhesion surgery sooner than 6 months had outcomes comparable with controls.

Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft.

A retrospective analysis was performed to explain the decreasing incidence of postoperative arthrofibrosis of the knee in 191 consecutive patients who had anterior cruciate ligament reconstruction using the central third patellar tendon from 1987 through 1991. Follow-up data were available on 188 patients (98%). Age, sex, time interval from injury, preoperative motion, and concomitant meniscal repair or partial meniscectomy were evaluated for their significance as risk factors. Twenty-two of 188 patients (12%) developed arthrofibrosis; the incidence was lower when the acute anterior cruciate ligament reconstruction was delayed at least 3 weeks from the injury, and when preoperative extension was 10 degrees or better. Age, sex, preoperative flexion, and need for concomitant meniscal surgery were not risk factors. The postoperative motion protocol evolved during the study period. Group 1 patients were braced in 45 degrees of flexion for 1 week before passive extension was allowed. In Group 2, motion was started after 48 hours. Group 3 patients were braced in full extension, with motion starting with 24 hours. With these changes, the incidence dropped from 23% to 3%. Decreases in the incidence of arthrofibrosis with modifications in operative technique and postoperative analgesia were not statistically significant.

Long-term results of open meniscal repair.

The purpose of this study was to document the long-term clinical and radiographic results of open meniscal repair. Thirty consecutive patients, involving 33 open repairs, were evaluated by history, physical examination, KT-1000 arthrometer testing, Lysholm II score, Tegner activity score, and weightbearing radiographs. The mean followup was 10.9 years (range, 10.1 to 13). No patients were lost to followup. Seven meniscal retears (21%) were documented (six demonstrated by repeat arthroscopy and one suspected on clinical evaluation). Three of 21 (14%) acute repairs (performed within 6 weeks of injury) retore as compared with 4 of 12 (33%) chronic repairs (P = 0.38). None of the 12 menisci in stable knees (< 3 mm side-to-side difference in anterior laxity on manual maximum load testing) sustained retears, compared with 7 of 21 (33%) menisci in nearly stable or unstable knees (P = 0.03). Standing radiographs revealed no degenerative changes in 22 of 26 (85%) compartments with successful repairs as compared with 3 of 7 (43%) compartments with retorn menisci (P = 0.04). We concluded that the long-term survival rate of repaired menisci was 79%, that increased retear rates were encountered in unstable knees, and that radiographs provided evidence for the biomechanical function of successful meniscal repairs.

Reflex sympathetic imbalance. Response to epidural blockade.

Eleven patients (two male, nine female) were treated with epidural sympathetic blockade for reflex sympathetic imbalance, an incomplete manifestation of reflex sympathetic dystrophy. Each had developed severe pain, sensitivity, and disability disproportionate to associated trauma. One patient injured an ankle, and the remaining 10 patients one or both knees (12 knees). Seven patients had undergone previous surgery. All but one had a favorable response to initial blockade. This individual eventually failed treatment despite surgical sympathectomy. Seven have required readministration of a block for clinical relapse. Mean followup was 22 months (range, 10 to 41 months). Five underwent extensive psychological testing. All have required adjunctive forms of therapy including physical therapy, transcutaneous electrical nerve stimulation (TENS), antiinflammatory or other nonnarcotic agents. Recovery is typically prolonged, particularly if the diagnosis is delayed. Close attention to, and therefore prevention of, situations that trigger its recurrence is essential for successful rehabilitation.

The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures.

A total of 18 competitive and recreational athletes were enrolled in a randomized, prospective study looking at the effect of pneumatic leg braces on the time to return to full activity after a tibial stress fracture. All patients had positive bone scans and 15 had positive radiographic findings by Week 12. There were two treatment groups. The traditional treatment group was treated with rest and, after 3 pain-free days, a gradual return to activity. The pneumatic leg brace (Aircast) group had the brace applied to the affected leg and then followed the same return to activity guidelines. The guidelines consisted of a detailed functional progression that allowed pain-free return to play. The brace group was able to resume light activity in 7 days (median) and the traditional group began light activity in 21 days (median). The brace group returned to full, unrestricted activity in 21 +/- 2 days, and the traditional group required 77 +/- 7 days to resume full activity. The Aircast pneumatic brace is effective in allowing athletes with tibial stress fractures to return to full, unrestricted, pain-free activity significantly sooner than traditional treatment.

Long-term followup of the modified Bristow procedure.

A total of 86 modified Bristow procedures were performed for anterior shoulder instability between 1975 and 1987. Followup on 79 shoulders (92%) was obtained at an average postoperative time of 8.6 years. The redislocation rate was 4%. Average motion loss was 5 degrees of internal rotation and 9 degrees of external rotation. Fifteen percent of the patients examined expressed mild apprehension with the shoulder abducted and externally rotated. Radiographic bone union of the coracoid transplant was noted in 82% of patients. Additional surgical procedures were required in 14% of patients. Seventy-three percent of the reoperations were for screw removal because of persistent shoulder pain. The average subjective shoulder function was rated at 86% of preinjury level. All throwing athletes were able to return to throwing, although 54% of the patients with dominant shoulder involvement noted a decrease in throwing velocity. Ninety-seven percent of the patients rated their results as good or excellent.

Principles of triangulation for arthroscopic surgery.

The basic principles of arthroscopic meniscal surgery involve precise identification of the type, extent, and location of the lesion, followed by conceptualization of the steps required to resect the torn portion of the meniscus, then appropriate selection of portals and instrumentation to carry out the procedure. The standard two-puncture technique of anteromedial and anterolateral portals frequently needs to be supplemented by accessory portals. A combination of large and small mechanical instruments is necessary, and powered instrumentation is often helpful. Triangulation techniques are sufficient for handling the vast majority of meniscal lesions suitable for arthroscopic meniscal surgery.

Decision-making in acute anterior cruciate ligament injury.

Acute surgical treatment is generally recommended for patients in the high-risk category. The relative frequency of surgical compared with nonsurgical treatment in any individual practice setting depends on the patient population and can vary widely from one practice to another even though overall indications may be quite similar.

Rationale for meniscus repair or excision.

A selective approach to meniscus lesions has evolved to replace the traditional approach of total meniscectomy for all tears. The rationale is to preserve as much functional meniscus tissue as possible in the hope of decreasing the risk of late degenerative sequelae and still relieve the symptoms associated with the meniscus tear. The principles that should be considered for the various treatment options of leaving certain tears alone, meniscus repair, partial meniscectomy, and total meniscectomy have been reviewed. The early to intermediate results of this selective approach are encouraging and warrant continuation of its use. It should be emphasized, however, that continuing follow-up studies are necessary to establish whether the primary goal of improving long-term results following meniscus surgery will be achieved.

Open meniscus repair. Indications, technique, and results.

As noted through the work of Fairbank, total meniscectomy is not a benign operation. Cox et al found that meniscectomies in canine knees lead to gross and microscopic degenerative changes. They also noted that partial meniscectomies lead to less severe degenerative changes. They believed that there was a direct relationship between the degree of degenerative change and the amount of meniscus removed. McGinty et al reported early return to function with decreased morbidity and decreased complication rates after partial meniscectomy; this was compared to both open and arthroscopic techniques for total meniscectomy. Jackson and Dandy have documented improved results of partial meniscectomy when compared with total meniscectomy in an intermediate range (average 5 to 10 years) follow-up study. Earlier studies by the senior author, Hamberg et al, and Cassidy and Shaffer have documented that meniscal repairs can heal. The more recent follow-up study of DeHaven et al has documented that repaired menisci not only heal satisfactorily but that durability and biomechanical function can also be maintained. Of course, long-term review of these same patients will be necessary to prove that successful repair will prevent the degenerative changes noted in knees following meniscectomy.

Arthroscopic medial meniscal repair in the athlete.

Meniscal tears are common sports injuries. This article details the clinical evaluation of the athlete presenting with knee pain. Conservative (nonoperative) treatment and arthroscopic procedures are discussed.

Pitfalls of the lateral retinacular release.

The treatment of patellofemoral pain is fraught with pitfalls; however, most of these pitfalls can be recognized. Results of LRR in appropriate circumstances are reasonably good, and the complications are acceptably low. Risk factors for poor results are identifiable, and avoidance of the common complications are necessary to achieve reliable results. Cases of persistent pain after LRR must be approached in a thorough and orderly fashion. There should be clear indications and cautious expectations for the success of subsequent procedures.