Marc J. Friedman

Accuracy of diagnoses from magnetic resonance imaging of the knee. A multi-center analysis of one thousand and fourteen patients.

Magnetic resonance images of the knee were made for 1014 patients, and the diagnosis was subsequently confirmed arthroscopically. The accuracy of the diagnoses from the imaging was 89 per cent for the medial meniscus, 88 per cent for the lateral meniscus, 93 per cent for the anterior cruciate ligament, and 99 per cent for the posterior cruciate ligament. The magnetic resonance examinations were done at several centers, and the results varied substantially among centers. The accuracy ranged from 64 to 95 per cent for the medial meniscus, from 83 to 94 per cent for the lateral meniscus, and from 78 to 97 per cent for the anterior cruciate ligament. The results from different magnetic-resonance units were also compared, and the findings suggested increased accuracy for the units that had a stronger magnetic field. Of the menisci for which the magnetic resonance signal was reported to be Grade II (a linear intrameniscal signal not extending to the superior or inferior meniscal surface), 17 per cent were found to be torn at arthroscopy.

Partial thickness rotator cuff tears: Results of arthroscopic treatment

Thirty-one patients with arthroscopically documented partial thickness rotator cuff tears treated by arthroscopic debridement of the lesion were retrospectively reviewed. The patients had had symptoms for an average of 20.5 months prior to surgery. Twenty-two of these 31 shoulders also had bursoscopy, with 18 having arthroscopic subacromial decompression. The results were graded by both the UCLA Shoulder Rating Scale and Neers criteria. Twenty-six (84%) of the patients had satisfactory results with the remaining 5 (16%) patients having unsatisfactory results. A classification system for the size and location of partial thickness rotator cuff tears is presented. The lesion size did not affect the result. Repeat arthroscopy in three patients demonstrated no further deterioration of their rotator cuff. The results with and without subacromial decompression were similar. The need for subacromial decompression is best determined by the arthroscopic finding of a bursal side tear.

Preliminary Results with Abrasion Arthroplasty in the Osteoarthritic Knee

A retrospective survey of 110 patients treated by arthroscopic debridement of the knee joint was conducted; 73 of 100 operations included abrasion arthroplasty. The average follow-up period was one year. All patients had Grade IV articular changes. Overall, 60% of the patients who underwent abrasion arthroplasty showed improvement, while the knee was unchanged in 34% and worse in 6%. The results were best in patients younger than 40 years of age. Forty-one patients had medial compartment abrasion in concert with pathologic medial meniscal conditions; 53% of these patients were improved. In a comparable group of 37 patients treated by medial compartment debridement and medial meniscectomy without abrasion only 32% showed improvement. Thus, tentative results in this small series of patients treated by abrasion arthroplasty are encouraging. Further investigations in a larger series are warranted to determine the long-term results of the procedure.

Critical Analysis of Knee Ligament Rating Systems

Sixty-five patients who consecutively underwent ante rior cruciate ligament reconstruction were studied using four individual, categoric, knee score rating systems. Different results were noted at followup (mean, 35 months; range, 24 to 58) depending on the rating method used. All patients were graded using the Hos pital for Special Surgery, Lysholm, Tegner activity, and Cincinnati Knee Ligament rating systems. The Cincin nati Knee Ligament rating individual scores were noted to be lower than the Hospital for Special Surgery and Lysholm scores for subjective and objective outcome assessment. The Hospital for Special Surgery and Lys holm scores did not correlate highly with the Cincinnati Knee Ligament rating final rating, but they did correlate with each other. The use of ligament rating scores tended to inflate results, particularly when raw scores were converted to overall categoric ratings (e.g., ex cellent, good). The Cincinnati Knee Ligament rating system correlates more highly with individual grading and most precisely defines outcome in athletically ac tive patients. Sources of error may be introduced by a disproportionate combination of unrelated scores or by overrating low-activity-level individuals who avoid stressing their knees. Avoidance of data generalization remains the optimal method for studying anterior cru ciate ligament surgery outcome.

Fracture of the Proximal Tibia With immediate Weightbearing after a Fulkerson Osteotomy

The records of 234 people who had anteromedializa tion of the tibial tubercle with oblique osteotomy be tween 1983 and 1994 at two separate institutions were reviewed retrospectively. Six patients (2.6%) had frac tures of the proximal tibia postoperatively, within 13 weeks of the Fulkerson osteotomy. All fractures oc curred after a change in the postoperative physical therapy regimen from partial weightbearing to immedi ate full weightbearing. All fractures healed with accept able alignment of less than 5° of varus-valgus or an teroposterior angulation. Given this increase in fracture incidence, a more conservative postoperative physical therapy regimen is recommended. All patients should be nonweightbearing initially, advanced gradually to partial weightbearing, and allowed full weightbearing only after the osteotomy has radiographic evidence of complete healing.

Four to ten year followup of unreconstructed anterior cruciate ligament tears

Both operative and nonoperative methods have been advocated for the treatment of ACL tears. However, the optimum management of this injury remains contro versial. In the present study, patients treated nonoper atively were evaluated retrospectively 4 to 10 years after ACL tears were documented by arthroscopy and by mild to moderate pivot shifts under anesthesia. Forty-nine patients who underwent arthroscopic eval uation of the knee between 1976 and 1982 were found to have complete tears of the ACL. A mild to moderate pivot shift was present under anesthesia. One or both menisci were torn in two-thirds of the knees, requiring partial meniscectomies. The average age of the patients was 27 years (range, 16 to 46 years). Because of persistent disabling instability, 9 patients (18%) under went late ACL reconstruction. The remaining 40 pa tients were evaluated at an average of 5.6 years after documentation of the tear (range, 4 to 10 years). At followup, 25 (62%) of the 40 patients had satisfac tory subjective results. Eight of the patients (20%) had returned to their preinjury level of athletic activities without restrictions, and 10 (25%) functioned at the same level but with symptoms, some patients requiring bracing. Seventeen patients (43%) had diminished their level of sports activities, while 5 patients (12%) had given up all sports. Only 2 patients required late men iscectomies. On physical examination, 27 patients (87%) had pivot shifts. Instrumented laxity testing revealed an injured to normal difference of 3.1 mm with a 20 pound force. Radiographic studies were interpreted as normal in 35% of the knees, whereas 65% demonstrated mild degenerative changes. Overall, objective results were satisfactory in only 7 (23%) of the 31 patients, although 19 (61 %) were satisfied with their functional results. Numerous procedures are available for stabilizing the ACL insufficient knee. With improvement in our ability to diagnose an acute ACL tear, management must be based not only on the initial clinical findings, but on the patients level of activity and functional expectations. Although only slightly more than 60% of the patients had satisfactory subjective results, many had adapted quite well to their ultimate functional disability through modification of activities. Few patients, however, re turned unrestricted to their preinjury level of function.

Patellar Instability: Treatment by Arthroscopic Electrosurgical Lateral Release

We reviewed the results of arthroscopic lateral release using electrosurgery in 39 patients (45 knees) with a history of recurrent patellar subluxation or dislocation. The average follow-up time was 28 months (range, 24-36). At follow-up, the patients had decreased swelling, instability, and pain. There was an improvement in flexion activities, sports participation, and overall functional ability. Only 20% of the knees had completely normal physical findings: 11.1% of the knees were rated as excellent; 64.4% were improved; and 24.5% were poor. Dislocators had more frequent poor results. The complication rate was 4.4%. There were no postoperative hemathroses. One patient was considered a surgical failure. The technique yields results comparable with those of open extensor realignment procedures and avoids the complications inherent to lateral release in general. The place for this procedure in patellar instability is well-documented.

Arthroscopic Partial Medial Meniscectomy: An Analysis of Unsatisfactory Results

Results of 150 arthroscopic partial medial meniscectomies were analyzed by computer to identify the factors that lead to an unsatisfactory (fair or poor) outcome. The average follow-up for the group was 36 months (range 24-60 months). One-hundred ten men and 40 women were involved, with an average age of 48 years. The overall results were 58% excellent-good, 28% fair, and 14% poor. Most tears involved the posterior horn (76%). Bucket-handle, longitudinal, and flap tears were rated 88% excellent-good, whereas horizontal cleavage and degenerative and complex tears had only 45% excellent-good scores. The results were adversely affected by the severity of the chondromalacia, work-related injury, prior knee surgery, simultaneous lateral meniscectomy, and increased knee laxity. Because degenerative posterior horn tears had such a high percentage of unsatisfactory results, the question remains as to whether all these tears need to be removed.

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.

Arthroscopic-assisted anterior cruciate ligament reconstruction with the semitendinosus tendon: Comparison of results with and without braided polypropylene augmentation

Fifteen chronic anterior cruciate ligament-deficient knees were arthroscopically reconstructed with a semitendinosus tendon polypropylene (STP) augmented composite graft. A comparison group of 28 reconstructions with the semitendinosus tendon (ST) but without augmentation was simultaneously reviewed. The mean follow-up in the STP group was 31 months (range of 24-42 months) and in the ST group it was 34 months (range 26-54 months). Both patient groups had similar age, sex, preinjury functional sports level, injury-to-surgery interval, and associated meniscal pathology. Good-to-excellent subjective results were reported in 86% of STP patients and 78% of ST patients, whereas 86% of the STP patients and 88% of the ST patients returned to sports activity. Objective examination revealed 73% of the STP group and 82% of the ST group to have a negative or 1+ Lachman test result. A negative pivot shift was noted at follow-up in 80% of the STP group and in 82% of the ST group. KT-1000 testing revealed 60% of the STP patients and 61% of the ST patients to have less than or equal to 3 mm of side-to-side difference. In the STP group there was no evidence of graft breakage, deep infections, or sterile effusions. Overall subjective and functional results were uniformly better than objective results in both patient groups. Analysis of subjective, objective, and functional results reveal no difference in outcome between the STP and the ST patient groups.