Gary G. Poehling

Cartilage injuries: A review of 31,516 knee arthroscopies

Although articular cartilage injuries of the knee are common, injured cartilage has a limited ability to heal. Recent data suggest that articular cartilage grafting may provide treatment for these injuries. To define the patient population that might benefit from cartilage grafting, 31,516 knee arthroscopies were reviewed. Between June 1991 and October 1995, 53,569 hyaline cartilage lesions were documented in 19,827 patients. The majority were articular cartilage lesions; grade III lesions of the patella were the most common. Grade IV lesions were predominantly located on the medial femoral condyle. Patients under 40 years of age with grade IV lesions accounted for 5% of all arthroscopies; 74% of these patients had a single chondral lesions (4% of the arthroscopies). No associated ligamentous or meniscal pathology was found in 36.6% of these patients.

Elbow Arthroscopy: A New Technique

Elbow arthroscopy is a useful diagnostic and therapeutic tool for the orthopedic surgeon. In the standard technique, the patient is positioned supine with the arm suspended overhead and an anterolateral portal is used. We have modified this technique by placing the patient in a prone position and using a proximal medial portal. Use of the prone position improves scope mobility, facilitates joint manipulation, and provides more complete intraarticular visualization. This technique simplifies the treatment of a wide variety of elbow pathology, including loose bodies, osteochondritis dissecans, persistent synovitis, suspected cartilaginous lesions, posterior osteophytes, selected radial head fractures, and chronically undiagnosed painful elbows.

New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies

The treatment of injuries to the triangular fibrocartilage complex (TFCC) has evolved from closed casting through open excision to arthroscopic repair. The authors present the preliminary results of arthroscopic repair of peripheral (Palmer type IB) TFCC tears using a Tuohy needle. Results in 17 patients treated with this technique were obtained retrospectively through chart review and telephone interview. Average age of the patients was 33 years (range, 16 to 54 years). Conservative treatment averaged 9 months (range, 2 to 26 months). The repairs were performed with one or two horizontal mattress sutures of 2-0 polydioxanone. Follow-up ranged from 4 to 13 months (average, 8 months). Sixteen patients were satisfied or very satisfied with the result; 1 was not satisfied. No complications occurred. We believe this Tuohy needle technique is practical and cost-effective for the arthroscopic management of peripheral TFCC tears.

Avoiding Catastrophic Complications of Stroke and Death Related to Shoulder Surgery in the Sitting Position

The beach-chair position in shoulder surgery provides advantages to the surgeon and anesthesiologist. However, cautious interpretation of the patients blood pressure is essential, especially when the blood pressure cuff is placed at the calf. The calf pressure should be interpreted relative to the heart-level pressure to avoid iatrogenic cerebral hypoperfusion related to hypotensive anesthesia. Possible complications of cerebral hypoperfusion are permanent neurologic impairment, stroke, and death.

Anterior interosseus nerve injury following elbow arthroscopy.

Elbow arthroscopy is becoming an increasingly invaluable tool for both evaluation of and treatment of a variety of interarticular disease processes. Case reports have documented radial and posterior interosseus injuries following anterior capsular release. To date, this is the first report of an anterior interosseus nerve injury following arthroscopic surgery of the elbow. Arthroscopic surgery offers unparalleled visualization of the multiple articulations and facets of the elbow. It has been reported as useful for removal of loose bodies, synovectomy, release of arthrofibrosis, and the treatment of osteochondritis dessicans. However, the technique does require thorough knowledge of neurovascular structures about the elbow as well as appreciation of the protective layers including the capsule, brachialis, and brachioradialis muscles. This report documents direct injury to the anterior interosseus branch of the median nerve during an elbow debridement and synovectomy in a 65-year-old patient with rheumatoid arthritis.

Reflex sympathetic dystrophy of the knee after sensory nerve injury

Reflex sympathetic dystrophy (RSD) of the knee is an extremely difficult problem to treat. This study examined the possible relationship between isolated injury to the infrapatellar branch of the saphenous nerve (IPBSN) and the etiology and natural course of RSD. Thirty-five patients with clinically significant sympathetic dystrophy of the knee were examined retrospectively. All patients (100%) had clinical evidence of insult to the IPBSN. Thirty-three patients (94%) were found to have vasomotor instability as measured by isolated cold stress testing (ICST). All patients in this population of 33 were treated with vasoactive therapies. Subjective improvement was noted in 20 patients (p = NS). Initial ICSTs of improved and unimproved patients were compared. Baseline temperatures were significantly warmer in patients who improved with therapy (p less than 0.05), and a warmer trend was evident throughout all phases of the test in those who improved compared with those who did not. Eighty percent of patients treated within 1 year improved with one or more vasoactive therapies, whereas only 44 percent improved when treatment was started after 1 year, indicating a significant population difference (p less than 0.05).

Current Concepts in Wrist Arthroscopy

The purpose of this article is to review the recent literature on arthroscopic treatment of distal radius fractures (DRFs), triangular fibrocartilage complex injuries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. A major advantage of arthroscopy in the treatment of DRFs is the accurate assessment of the status of the articular surfaces and the detection of concomitant injuries. Nonrandomized studies of arthroscopically assisted reduction of DRFs show satisfactory results, but there is only 1 prospective randomized study showing the benefits of arthroscopy compared with open reduction-internal fixation. Wrist arthroscopy plays an important role as part of the treatment for DRFs; however, the treatment for each practitioner and each patient needs to be individualized. Wrist arthroscopy is the gold standard in the diagnosis and treatment of triangular fibrocartilage complex injuries. Type 1A injuries may be successfully treated with debridement, whereas the repair of type 1B, 1C, and 1D injuries gives satisfactory results. For type 2 injuries, the arthroscopic wafer procedure is equally effective as ulnar shortening osteotomy but is associated with fewer complications in the ulnar positive wrist. With interosseous ligament injuries, arthroscopic visualization provides critical diagnostic value. Debridement and pinning in the acute setting of complete ligament tears are promising and proven. In the chronic patient, arthroscopy can guide reconstructive options based on cartilage integrity. The preliminary results of wrist arthroscopy using electrothermal devices are encouraging; however, complications have been reported, and therefore, their use is controversial. In dorsal wrist ganglia, arthroscopy has shown excellent results, a lower rate of recurrence, and no incidence of scapholunate interosseous ligament instability compared with open ganglionectomy. Arthroscopy in the treatment of volar wrist ganglia has yielded encouraging preliminary results; however, further studies are warranted to evaluate the safety and efficacy of arthroscopy.

Arthroscopic reconstruction of the anterior cruciate ligament using allograft tendon.

Treatment of the anterior cruciate ligament (ACL)-deficient knee using an arthroscopic technique and freeze-dried allograft tendons in 23 patients was studied prospectively. Accurate placement of drill holes and anchoring positions for the allografts was effected through a standard arthroscopic approach combined with a 3 cm incision on the medial tibial flare. Candidates for reconstruction were those who were unable to tolerate brace therapy and who had no degenerative arthritis. The 23 patients were drawn from a group of 60 treated patients because their follow-up had been greater than or equal to 1 year. Their knees were assessed preoperatively and postoperatively with a Lysholm knee rating scale, Lachman test with KT-1000 arthrometric quantitation, pivot shift, Biodex test, and radiographs. Knee rating values improved in all knees, and only one patient had a significant deterioration in the KT-1000 reading. All patients with at least 20 months follow-up have resumed their preinjury activity levels.

Two Steps Forward, One Step Back

In Mixed Signals, Kathryn Sikkink has crafted a wellwritten, succinct, and engaging overview not only of the general evolution of the human rights tradition in U.S. foreign policy, but also of its specific application and manifestation in U.S. relations with Latin America. While this book will appeal principally to students of U.S. international relations, and specifically to students of U.S.-Latin American relations, its attention to the evolution of the human rights agenda in Congress and in various U.S. executive agencies also offers an excellent case study of how foreign policy is rooted in the domestic political culture and political system of the United States.

An experimental assessment of the risk of compartment syndrome during knee arthroscopy

The purpose of this study was to objectively evaluate the risk of compartment syndrome as a complication during arthroscopy, particularly with the use of mechanical infusion systems. Little experimental data are available. This study shows that when elevated compartment pressures occur, extravasated fluid dissipates quickly, minimizing the risk of compartment syndrome and subsequent neuromuscular damage. Twelve live pig hind limbs (six swine) were used. Three additional limbs were used as shams. After anesthesia and portal placement for mechanical fluid infusion, two standardized capsulotomies were created to allow free extravasation of fluid. We dynamically monitored intraarticular pressure, and intracompartmental pressure in the anterior (leg), deep posterior (leg), and quadriceps (thigh) compartments. Nerve conduction studies were performed on the tibial and peroneal nerves. Data collection began at the onset of fluid infusion and continued after infusion ceased until elevated compartment pressures fell below 20 mm Hg. There were two study variables: intraarticular pressure (100, 150, or 200 mm Hg) and time of fluid ingress (30, 60, or 90 minutes). Following this, the swine were evaluated serially for 13 to 16 days. Repeat nerve conduction studies, muscle biopsies (in the three previously mentioned compartments), and electromyography were performed 13 to 16 days following the operation. Maximum compartment pressures during fluid infusion averaged 78.75 mm Hg. Significant variability existed when comparing the interrelationships of infusion time, maximum compartment pressures, time of resolution of elevated pressures, and intraarticular pressures. Most importantly, elevated compartment pressures resolved quickly (mean, 25.5 minutes; range, 0 to 100 minutes; n = 36 compartments) when stopping fluid infusion. Nerve conduction studies were normal on all postoperative studies. Electromyographic (EMG) analysis showed normal study results in the biceps, gracilis, abductor digiti quinti, and adductor digiti segundi. Although EMG analysis of the tibialis anterior and extensor digitorum brevis showed 1+ fibrillation (1+ to 4+ scale), this was seen in sham studies with tourniquet alone (no fluid infusion). Muscle biopsies were without evidence of myonecrosis. Finally, 5 of 6 swine ambulated without difficulty on the first postoperative day, whereas 1 swine limped for 2 days. All swine were normal by the 3rd postoperative day and also at the end of the study. These data show that in this model, the risk of developing sequela from compartment syndrome during arthroscopy is minimal, even when there exists significant fluid extravasation and elevated compartment pressures.