Arthroscopy and irrigation control.

Saline flow through 2.2, 3.8, and 5.0 mm arthroscopes was studied by varying inflow pressure from 0 to 20 kPa, corresponding to the effect of gravity from 0 to 7 feet. The relation between knee joint distention and intraarticular pressure was studied in 25 patients under general anesthesia, and the secondary effect on gravity flow was calculated. Without distention, flow due to gravity alone was adequate through the larger arthroscopes, but diminished rapidly to low values by distending the joint. Even with a 5.0 mm arthroscope and bags at 7 feet (20 kPa), inflow was low when the joint was distended for arthroscopy. Effective clearing by high flow, combined with distention for hemostasis of capsular vessels, demands the use of a pump. Pump irrigation is most effective and also safe when controlled directly by the surgeon.

Arthroscopy of the shoulder joint (technique).

The results are reported of using different telescopes and different approaches in arthroscopy of the shoulder joint. This joint is particularly suitable for arthroscopic investigation and its use will no doubt increase considerably in the near future because of its considerable potential as an aid to diagnosis and treatment.

Arthroscopic partial meniscectomy. Technique and long-term results.

The functional results in 125 patients treated by arthroscopic meniscectomy were reviewed two to four years after operation. Arthrotomy was necessary to complete the procedure in 15 cases and done at the same session. The other 110 cases were evaluated in a follow-up questionnaire study, which included a knee function rating system. The postoperative rehabilitation period was very short, with the majority of patients returning to work within two weeks. Most athletic patients returned to their preinjury level within four weeks. The best functional results were obtained in cases with an isolated meniscal lesion. The presence of osteoarthritis or chondromalacia had a negative effect on the results, although 50% of affected patients who were rated fair or poor stated that their knee function was improved after the procedure. Of the patients, 20% had associated instability of the knee primarily owing to cruciate insufficiency. These patients often noted no improvement after treatment of the meniscal lesion alone. Of these patients, 28% were eventually treated by open knee surgery to correct the instability. The results of arthroscopic meniscectomy are best in knees with isolated meniscal tears, but subjectively improved knee function can also be expected in some patients who have degenerative joint disease. In unstable knees, endoscopic meniscectomy is often not the treatment of choice, except in selected cases where a stabilizing operation is contraindicated.

Different techniques for diagnostic arthroscopy. A randomized comparative study.

A randomized comparison between the anterolateral approach and the Needlescope technique for knee joint arthroscopy in 121 consecutive patients is presented. The central approach was used a reference, and the results of the other two techniques were compared with the results of this technique in the same patient. It is shown that the Needlescope necessitates a multiple puncture technique to give reliable information. When so used the results were comparable with those obtained with Storz arthroscopes and the central approach. On the other hand, the anterolateral approach gave less accurate results, mainly because of the difficulties encountered in examining the posterior compartments.

Arthroscopic visualization of the posteromedial compartment of the knee joint.

Introduction of the arthroscope in the midline through the patellar tendon about 1 cm. below the apex of the patella is described. The posterior compartments of the knee joint can be examined from this single entry. The technique has been used in 1232 patients without any complications. In 127 patients subjected also to arthrotomy the arthroscopic diagnosis proved to be correct in all instances except for one missed rupture of the posterior cruciate liagment. In that case a bucket handle rupture of the medial meniscus prevented the entry into the posteromedial compartment.

Long term results of surgery for non-acute anteromedial rotatory instability of the knee.

Seventy-eight patients treated by extraarticular reconstruction including pes anserinus transfer for anteromedial rotatory instability of the knee were reinvestigated 16--47 months (mean 28) after operation. Function before and after operation was assessed by means of a knee rating score. Of these patients, 94 per cent showed a higher score after operation. Twenty per cent showed full recovery with no limitation of knee function whatsoever. The follow-up score was higher with preserved medial meniscus function than when this structure had been removed. When not initially torn, the medial meniscus tended to become involved with time. Mild laxity in extension, possibly indicative of a posterior cruciate injury previously underestimated or not observed, was found in 15 per cent of the patients. No correlation was found between late knee function and the interval between injury and operation or the interval between operation and follow-up examination. The long term results were good. Extraarticular reconstruction is thus indicated in cases of chronic rotatory instability of the anteromedial type. Routine meniscectomy is not recommended in these patients, however. Signs possibly indicating posterior cruciate ligament involvement should be carefully looked for, as even minor posterior cruciate injury, easily overlooked, may influence the late results.

Arthroscopic examination of the posteromedial compartment of the knee joint.

In a series of 356 arthroscopies of the knee joint 127 patients were explored by arthrotomy. A Storz arthroscope was introduced through the patellar tendon, and we alternated between the 30 degrees and 70 degrees optical systems in the same trocar sheath. The 30 degrees system was used for inspection of the superior, anterior, medial and lateral compartments, and to lead the tip of the instrument to the posterior part of the joint. The 70 degrees telescope was then used, providing a good view of the posterior cruciate ligament and the posterior horn of the menisci and their attachments. It also allowed direct inspection of the posterolateral and posteromedial compartments. No major diagnostic error was made by the arthroscopist in the 127 patients operated on as a result of the findings of endoscopic examination. Arthroscopy with the use of both 30 degrees and 70 degrees telescopes at the same session gives high diagnostic accuracy and detailed, exact pre-operative diagnosis.

Transcutaneous meniscectomy under arthroscopic control.

A technique of arthroscopic excision of a torn meniscus has evolved during two years' experience of therapeutic arthroscopy of the knee joint. The same method is used for both medial and lateral meniscus lesions under full visual control throughout the procedure, with a standard arthroscope inserted centrally through the patellar tendon. The first 18 consecutive patients thus treated have been followed up. Endoscopic operation was complemented by arthrotomy in three; in 15 no other treatment was given. The time in hospital, convalescence, sick leave, and knee function at follow-up were compared in these 15 patients with matched controls treated in the ordinary way by arthrotomy. Knee function did not differ between the groups, whereas all other variables showed better results after arthroscopic excision.

Therapeutic arthroscopy of the knee.

This paper describes transcutaneous therapeutic procedures performed during arthroscopy. Sixty-six patients were treated. Small loose bodies were flushed out through the arthroscope in 7 cases. In 19 of 24 knees a loose body 0.5-2 cm in size was extracted either with a Dormia stone-dislodger or a pituitary rongeur. In 5 patients we failed to remove the loose body transcutaneously and arthrotomy was performed. A meniscus was resected in 17 patients using a pituitary rongeur alone or in combination with some other instrument. The late result was good in 14, but 3 subsequently underwent arthrotomy. Various procedures such as lateral release of the patella by a special technique, removal of intra-articular sutures and other measures were also undertaken. No complications occurred and the duration of sick leave was usually short. Before arthrotomy for removal of loose bodies or resection of ruptured menisci is performed, we feel that an attempt at transcutaneous therapy under arthroscopy should be made.

Immediate effects of meniscectomy on the knee joint. The effects of tensile load on knee joint ligaments in dogs.

Tensile strength variables for the collateral ligaments were compared after excision of the meniscus in one knee, the corresponding meniscus in the contralateral knee of the same dog being intact. Removal of the meniscus was associated with a three-fold increase in initial laxity, two-fold for the lateral and three-fold for the medical ligament. The maximum tensile load uptake of the medial collateral ligament was reduced by more than 10 per cent after medial meniscectomy; the load uptake of the lateral ligament was not affected by lateral meniscectomy. It is proposed that tensile loads are distributed more favourably in the medial collateral ligament by the intact medial meniscus with firm capsular attachments than in the "normal" ligament after meniscectomy.

Arthroscopy in acute injuries of the knee joint.

Arthroscopy was performed during the acute phase of injury in 84 knees (79 patients). A satisfactory view of the joint was obtained in all cases, and no complications occurred. About two-thirds of the patients had injuries associated with violent rotation-abduction. In about one-third of the patients operation could be avoided. In cases with haemarthrosis, serious ligament injury was present in nearly 50 per cent. Complete arthroscopy was associated with few diagnostic errors. Clinical examination often led to uncertain or incorrect diagnosis even when performed under anaesthesia by experienced surgeons. In contrast, arthroscopy led to rapid diagnosis and treatment, thus shortening the period of disability. We recommend arthroscopy in acute knee injuries, but the examination must be performed by an experienced arthroscopist.