Isolated arthroscopic meniscal repair: a long-term outcome study (more than 10 years).

A single surgeon's consecutive series of 50 arthroscopically repaired meniscal tears in 48 patients was retrospectively reviewed. None of these patients had concomitant ligament damage to the knee. The average follow-up period was 10 years, 9 months. Criteria for clinical success included 1) history of pain of grade 1 or less and absence of locking, catching, or giving way; 2) a physical examination demonstrating no significant effusion and a painless and negative jump sign; and 3) no subsequent surgical procedures on the repaired meniscus. Patient satisfaction was quite high, although clinical confirmation was possible in only 38 knees, indicating a clinical success rate of 76%. Bilateral standing radiographs were obtained on these 38 operated knees and were evaluated using Fairbank's classification. Evaluation of the radiographs revealed that 8% of the operated knees had minimal joint changes, as compared with 3% in the contralateral, nonoperated knee. This study demonstrates that arthroscopic meniscal repair in knees with isolated meniscal tears has the potential for a long-term successful clinical and radiographic outcome.

Effect of bone block removal and patellar prosthesis on stresses in the human patella.

Thermoelastic stress analysis was used to examine stresses on the anterior surface of patellae after patellar bone block excision for autogenous graft anterior cruciate ligament reconstruction. Complications of anterior cruciate ligament injury often lead to degenerative changes in the knee that can require total knee joint replacement. It was hypothesized that stresses in a bone block-compromised patella may be increased even further by insertion of a patellar prosthesis. All patellae were first tested intact and then were retested after a sequence of surgical modifications including patellar prosthesis implantation, tapered bone block excision, square bone block excision, and both shapes of excised bone blocks with a patellar prosthesis in place. Stresses in patellae with bone blocks excised were significantly greater than stresses in intact patellae. The anterior surface stress pattern in the loaded patella was significantly altered by excision of a bone block. There were no significant differences between maximum stress in patellae with tapered and square bone blocks excised. A finite element analysis showed that excision of a larger trapezoid-shaped bone block greatly increased maximum stress levels. Insertion of a patellar prosthesis did not significantly alter stress patterns or maximum stress levels in the patella.

Anterior cruciate ligament reconstruction stability with continuous passive motion. The role of isometric graft placement.

A comparison was made of the stability of isometric versus nonisometric anterior cruciate ligament (ACL) reconstructions when subjected to immediate postoperative continuous passive motion (CPM). Anterior cruciate ligament reconstructions were performed on 13 anatomic specimen knees using bone/patellar tendon/bone grafts. Nine ACL substitutions were considered isometric with maximum graft length changes of less than 1 mm. Four ACL substitutions were nonisometric with graft length changes of 3 mm or greater resulting from tightening in flexion. The specimens were subjected to CPM through 0 degrees-95 degrees knee flexion. Knee stability was remeasured with a knee arthrometer at three and 14 days after beginning CPM. All four nonisometric specimens had failed within three days, with increased anterior laxity of 2-9 mm in both the Lachman (20 degrees) and anterior drawer (90 degrees) positions. All nine isometric reconstructions successfully retained pre-CPM anterior stability within 1 mm after 14 days of CPM. This investigation illustrates the importance of isometric graft placement for ACL reconstruction success. Continuous passive motion does not appear to adversely affect immediate ACL-substitute integrity or fixation if graft placement is isometric (less than 1 mm of graft excursion through 0 degrees-110 degrees of knee motion). Continuous passive motion may cause graft deformation, fixation failure, or both, with resultant loss of knee stability if the graft is not isometrically positioned (greater than 3 mm of graft excursion resulting from tightening in flexion).

Use of the fascia sheath coverage and exogenous fibrin clot in the treatment of complex meniscal tears.

In a previous series, complex meniscal tears, including double flap, double longitudinal, and radial tears, there was reported a high failure rate (14 of 58 repairs, 24%) when treated by conventional arthroscopic repair techniques. There was only one tear in the anterior middle one-third of the lateral meniscus in this group. The use of a fascia sheath to cover the repaired area improves healing rates an additional 17% (from 75% to 92%) with these tear classifications, with the exception of radial split tears in the middle one-third of the lateral meniscus. The present repair technique includes rasp abrasion of the parameniscal synovium, peripheral white rim, and tear surface of the handle fragment. The meniscus is sutured with fully diverged sutures. A rectangle of fascia from the distal anterolateral thigh, trimmed to 25 x 35 to 40 mm, is prepared with the double-armed meniscus suture run along opposite sides. One or two "hold-down" sutures are tied to the superior and inferior main sutures. The four hold-down sutures from the corners and the previously placed hold-down sutures are pulled through the capsule with previously placed pull-through sutures to pull the fascia over the meniscal repair. The exogenous blood clot is injected in the tear under the sheath. This preliminary report suggests that improved healing rates can be obtained with most complex tears by meticulous meniscal repair followed by coverage with the fascia sheath and then exogenous clot injection. Repairs of tears in the middle one-third of the lateral meniscus still show a high failure rate.

Current status of meniscus salvage.

The direct repair of meniscus tears with rasp preparation of all tear surfaces, stable suture fixation, and exogenous clot injection is effective for single longitudinal tears with peripheral white rims of 4 mm and less. Radial split and flap tears at the posterior horn of the lateral meniscus can be directly repaired as well. Single longitudinal tears typically in chronic knees with peripheral white rims of 5 mm and greater may have better reliability with use of the fascia sheath. The sheath is indicated in complex tears including flaps and radial splits. A structured rehabilitation program is necessary for improved reliability of meniscus healing. Tears out in the white substance are significantly more sensitive to rapid return to weight bearing than the peripheral tears or the ligament-reconstruction portions of the procedure. Contraindications to meniscus repair would include short tears (less than 10 mm), stable partial thickness tears with less than 50% of the vertical height of the meniscus torn, and shallow radial tears of 3 mm depth or less. A posterior incision and use of the popliteal retractor at all times are necessary for protection of the popliteal neurovascular structures.

Arthroscopic meniscal repair using an exogenous fibrin clot.

In this series of 153 meniscus tears, 8% were isolated whereas 92% were in conjunction with anterior cruciate ligament (ACL) tears. Exogenous fibrin clot was injected with a blunt needle in the seam of the tear. One to 2 ml of clot was sufficient to fill an average defect. When gaps could not be closed, such as with a radial split or flap in the posterior one-third of the meniscus, a fascia sheath was used to cover these defects and the exogenous clot was injected under the cover of the sheath. ACL-deficient knees were stabilized with an intraarticular reconstruction. Overall results were 64% healed, 24% incompletely healed, and 12% failed (less than 50% of vertical height of tear healed). In ACL-associated knees, the failure rate was 1.5% for tears in which surgery occurred up to two months after the time of injury. The failure rate for tears surgically treated two months to several years after injury was 20%. Complex tears had an even higher failure rate of 22%. It is these tears that will be treated with the fascia sheath. The isolated tear failure rate was 41% without the exogenous fibrin clot versus 8% with the exogenous clot. Complications included retear and popliteal neurovascular injury. Repair of almost all menisci in young active athletes is possible using the transarticular arthroscopic technique with a posterior incision. Repairs of tears of less than two months' duration from the time of injury to surgery result in significantly higher healing rates than those of more chronic tears. Isolated repairs heal significantly better with exogenous fibrin clot injection.

Arthroscopic meniscus repair with a posterior incision.

The transarticular arthroscopic approach with a posterior incision provided a method of repairing more than 98% of unstable meniscus tears encountered between November 1983 and November 1986. A clinically stable bond was obtained in most of these tears with a subjective failure rate of 2% or less. There was a trend towards better healing of isolated meniscus repairs and lateral meniscus tears less than eight weeks old associated with ACL reconstruction when a blood clot injection was used to supplement the rasp abrasion of the parameniscal synovium. Healing of rim widths to 5 mm can be obtained with these methods. Indications for meniscus repair include all lateral meniscus tears and all medial meniscus tears except when repair of a stump would not replace 25% or more of the missing area. In our experience, this includes more than 98% of all unstable meniscus tears. Contraindications to meniscus repair include short (10 mm or less) stable tears, partial thickness (less than 50% of vertical height), and shallow radial tears (3 mm or less in depth). The posterior incision and popliteal retractor are necessary to protect the popliteal neurovascular structures.

The relationship of the femoral attachment site to the isometric tracking of the anterior cruciate ligament graft.

The large number of reconstructive procedures in the treatment of ACL reflect a lack of consistent clinical success, thus creating the current controversy over the treatment of ACL injuries. The purpose of this study on the relationship of the femoral attachment site to the isometric tracking of the ACL graft was three-fold: 1) to develop a method for evaluating the femoral attachment site for the ideal isometric graft tracking pattern; 2) to develop a reference table comparing femoral attachment sites to graft excursion; and 3) to apply this information to the surgical procedure to allow for stepwise refinement of the attachment site for improved clinical results. To aid in graphic representation, the attachment sites were identified from radiographs by the sclerotic margin of the drill hole in the bone or the bone trough. These attachment sites were transferred to a trace diagram and compiled to form a composite diagram. Three distinct graft tracking patterns were identified. Group I represented the modified "over-the-top" technique with a deep cancellous bone trough and represented the most isometric tracking. Group II represented the modified over-the-top technique with a shallow or no cancellous bone trough and Group III the drill hole technique. Groups II and III were nonisometric. In surgery, palpation of the graft for excursion while performing a range of motion allows for review of isometric graft tracking. Stepwise intraoperative refinement of the femoral attachment site can result in isometric graft tracking.

Vascularity for healing of meniscus repairs.

Vascularity in the human meniscus is poor beyond 1-2 mm from the meniscosynovial junction, yet 22% of the tears in this series occur with a greater than or equal to 3-mm peripheral white rim. It is possible to suture these tears with the wider peripheral white rims, but healing rates are reduced because it is more difficult to obtain a satisfactory vascular supply. This article describes the history of our efforts at obtaining blood supply for healing of meniscus tears with a peripheral white rim up to 5 mm. Resection of the peripheral white rim to the vascular bed was unsatisfactory because it reduced the size of the meniscus and, by 3 years, the subsequent degenerative changes in the knee were comparable to meniscectomy. Holes made in the rim with a biopsy needle were again unsuccessful at improving healing. The present technique involves using rasps to abrade the parameniscal synovium on both the superior and inferior surface of the peripheral white rim. None of the peripheral white rim is resected. In the first series of 240 patients in whom peripheral white rim resection or the biopsy punch was used, the failure rate of meniscus healing was 22%. In a subsequent series of 68 patients (52 males, 16 females) who had 81 meniscal repairs by means of the rasp for parameniscal synovial abrasion, the failure rate was 9%. The rasp appears to be the safest and most effective method to gain vascularity for healing of meniscus repairs. It is possible to obtain healing with 5-mm peripheral white rims without resection of any portion of this rim, thus maintaining the full size of the meniscus.

Acute ligamentous diastasis of the ankle without fracture. Evaluation by radionuclide imaging.

Diastasis of the ankle syndesmosis without fracture is an uncommon injury. We present the results of bone scintigraphy as well as stress radiographs of the ankle performed on 27 athletes with suspected acute diastasis of the ankle without fracture. Scintigraphy is a reliable procedure to guide initial management of those patients in whom stress radiographs of the ankle cannot be obtained because of pain or swelling, or in whom the radiographs were considered unreliable. Scintigraphy correctly identified all 20 patients with positive stress tests (sensitivity = 100%). Two of seven patients with negative stress tests had positive scans (specificity = 71%), for an accuracy of 93%. We feel that scintigraphy is of value in a small subset of patients with suspected acute diastasis of the ankle syndesmosis on whom stress radiographs cannot be performed, or are considered inadequate in the immediate postinjury period.

Exercise-related stress reaction of the sacroiliac joint. An unusual cause of low back pain in athletes.

Low back pain, secondary to a variety of musculoskeletal injuries, is common in individuals engaged in athletics. Sports-related stress reactions of the pars interarticularis are not uncommon. Stress reactions of the sacroiliac joint, on the other hand, are considered very rare. The limitations of plain radiographs and the ability of bone scintigraphy to detect stress lesions in athletes is well documented. In this paper we describe four young athletes with stress reactions of the sacroiliac region. We consider these to be uncommon but not rare, and probably self-limiting. Accurate diagnosis is important, however, to exclude more important causes of low back pain that require therapy. This type of injury also results in abnormal stresses to the lower extremities which can result in an independent and more serious injury. All sacroiliac stress reactions were unsuspected and were diagnosed only by bone scintigraphy after plain radiographs were noncontributory.

Combined posterior incision and arthroscopic intra-articular repair of the meniscus. An examination of factors affecting healing.

Using intra-articular techniques for meniscal repair, several factors associated with meniscal lesions were analyzed prospectively to determine their effects on healing of the repair. Although 260 medial or lateral meniscal repairs in 240 patients were done, 178 repairs in the 167 patients who were followed by postoperative arthroscopy or arthrography form the basis of this study. The results of the repairs were classified as healed, incompletely healed, or not healed. The average duration of follow-up was 100 weeks (range, twenty-eight to 231 weeks). By arthrographic or arthroscopic criteria, 61.8 per cent of the menisci healed, 16.9 per cent healed incompletely, and 21.3 per cent did not heal. Ninety-two per cent of the menisci were categorized as clinically stable, and 80 per cent of the patients returned to active sports participation. Positive correlations with healing were found in patients who had a narrow peripheral meniscal rim (zero to two millimeters) (p = 0.03) and in patients who had a repair that was associated with reconstruction of the anterior cruciate ligament (p = 0.0001).

Current concepts of meniscal function and pathology.

The advantages of preserving the menisci are reduced degenerative changes and improved stability. At long-term follow-up, even arthroscopic partial meniscectomy in the anterior cruciate ligament-deficient knee results in more than twice the incidence of Fairbank's changes compared with a normal meniscus, stable meniscus tears left alone, or meniscus repair.

An in vivo strain gage study of elongation of the anterior cruciate ligament.

The purpose of this paper is to study the load-elongation characteristics of a Grade II sprain of the anterior cruciate ligament (ACL) at the time of local anesthesia arthroscopy. The data may be used to increase diagnostic and prognostic accuracy when evaluating Grade II ACL sprains and to structure properly a rehabilitation program following ACL injury. This report is based on the data from two in vivo strain gage studies of Grade II ACL sprains. Following instrumentation of the ligament, several events common to physical examination and rehabilitation programs were tested. The Lachman test produced greater elongation of the anteromedial fibers than did the anterior drawer or pivot shift test. A fairly high force of 80 pounds may be required by the examiner's hands to test satisfactorily the anteromedial fibers in the acutely injured large athlete. The proper order for a rehabilitation program should be crutch walking, cycling, walking, slow running, and faster running. Patients should be cautioned to run on a perfectly level surface. Cycling produced 7% as much elongation as an 80 pound Lachman test, and the one leg half squat 21% as much. Quadriceps rehabilitation can be done more safely using these exercises. Quadriceps exercises by knee extension against a 20 pound weight boot in the range of full extension to 22 degrees flexion created peak elongation of the anteromedial fibers ranging from 87 to 121% of that produced by an 80 pound Lachman test. We recommend that quadriceps exercises and testing by knee extension through a full range of motion not be done during the first year following ACL injury or reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of meniscus tears of the knee by radionuclide imaging.

We compare the accuracy of radionuclide imaging of the knee with Tc99m-pyrophosphate with arthrography for the evaluation of meniscus tears in young athletes with clinically suspected knee injury. All patients had arthroscopy which was used as the standard against which the other two diagnostic procedures were compared. Radionuclide scintigraphy and arthrography were comparable in their ability to detect tears of the medial meniscus. Scintigraphy was superior for the detection of tears of the lateral meniscus and of both menisci.

Arthroscopic repair of meniscus tears.

Arthroscopic repair of torn menisci using a bent-tip Keith needle is described. Experience with the technique over a seven-year period is summarized.