James M. Fox

Degeneration and Rupture of the Achilles Tendon

An analysis was perfomed on 32 operative cases of Achilles tendon disease. Two patient classifications emerged. One group suffering an acute rupture of the Achilles tendon with no antecedent complaints, and the second group had a history of chronic pain, weakness and functional loss. This latter group could be further differentiated by the occurrence of tendon failure in 10 of 22 cases. Surgical exploration in the group with chronic complaints demonstrated a high incidence of diffuse reactive changes such as fibrinoid and myxomatous degeneration, fibroisis and metaplastic calcification. Degenerative disease of the Achilles tendon should be recognized and treated not as a simple injury but as a pathological lesion.

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 medial meniscectomy. In an average of 2.0 years after initial surgery to the knee, 210 patients required subse quent surgical procedures for progressive meniscal pathology (38), articular cartilage damage (64), or ligamentous instability (108). The recognition of the possibility 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 this 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 pro cesses.

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.

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 sub stitution using a meniscus (25 patients) or central third of the patellar tendon (17 patients). Subjective and objective evalua tions 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 pri marily based on the surgeons technical ability to correct completely all components of anterior instability at the time of surgery. Subjective results were multifactorial and were cor related 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 cru ciate substitutions was the average loss of 6° of flexion in the central third of the patellar tendon group. Both the patellar tendon and meniscus clinically appeared to be successful in traarticular cruciate substitutes which can predictably correct moderate to severe anterior instability of the knee in a high percentage of patients.

Fracture of the patella due to overuse syndrome in a child A case report

a partial or complete fracture of bone due to inability to withstand nonviolent stress that is applied in a rhythmic and repeated subthreshold manner.&dquo; Stress fractures were first described by German military surgeon Breithaupt in 1885,’ and roentgenographic confirmation was first reported by Stechow19 in 1897, documenting metatarsal fractures in army recruits. Stress fractures of the patella in adult athletes have been reported in the medical literature, but no series has reported stress fractures of the patella in child athletes.9,1O A report by Kaye and Freiberger12 described fragmentation of the inferior patellar pole in seven children with

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 ligamentous 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 ex amined 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.

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.

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.