Richard D. Ferkel

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.

Arthroscopic Treatment of Chronic Osteochondral Lesions of the Talus: Long-Term Results

Background Osteochondral lesions of the talus are relatively uncommon but may be a cause of significant pain and disability in symptomatic patients. Hypothesis Arthroscopic treatment of osteochondral lesions of the talus will result in good long-term clinical outcomes in the majority of patients. Study Design Case series; Level of evidence, 4. Methods Fifty patients with chronic osteochondral lesions of the talus underwent arthroscopic treatment. Average age was 32 years (range, 12-72 years). Average follow-up was 71 months (range, 24-152 months). Treatment consisted of either drilling of the osteochondral lesions of the talus in situ (n = 4), excision of the osteochondral lesions of the talus and abrasion arthroplasty (n = 6), or excision of the osteochondral lesions of the talus and drilling (n = 40). Preoperative and intraoperative staging of the osteochondral lesions of the talus was performed. Follow-up evaluation included 3 clinical rating systems: Alexander, modified Weber, and American Orthopaedic Foot and Ankle Society Ankle/Hindfoot scores. Results There were 72% excellent/good, 20% fair, and 8% poor results on the Alexander scale. According to the modified Weber scale, there were 64% excellent/good, 30% fair, and 6% poor results. The average American Orthopaedic Foot and Ankle Society Ankle/Hindfoot score was 84 (range, 34-100). We found no correlation between plain radiographs, computed tomography, or magnetic resonance imaging staging and clinical results. However, there was significant correlation between arthroscopic stage and clinical outcome. Seventeen patients had been seen 5 years previously and evaluated using the same criteria; 35% demonstrated a deterioration in their result over time. Conclusion Arthroscopic treatment of chronic symptomatic osteochondral lesions of the talus results in good clinical outcomes in the majority of patients. However, pain and functional limitation may persist in some patients, especially those noted to have unstable osteochondral defects at the time of arthroscopy.

Neurological complications of ankle arthroscopy

A retrospective review of the first 612 patients undergoing consecutive ankle arthroscopy in the practices of two experienced arthroscopists was under-taken. All inpatient records, outpatient charts, and operative reports were reviewed. Indications for surgery included pain, swelling, locking, and instability that failed to respond to nonoperative management. The results of our investigation revealed an overall complication rate of 9.0% (55 complications). There were 27 neurological complications (4.4% of all arthroscopies) accounting for 49.1% of the complications noted. Specifically, the superficial peroneal nerve was injured in 15 cases, the sural nerve in 6, the saphenous nerve in 5, and the deep peroneal nerve in 1. All nerve injuries occurred through direct injury by portal or distractor pin placement. No cases of neurological injury caused by tourniquet compression or compartment syndrome were seen. Also, 1 case of reflex sympathetic dystrophy was identified.

Arthroscopic Findings Associated with the Unstable Ankle

Before lateral ankle stabilization, arthroscopic surgery was performed on 54 patients (55 ankles) with chronic ankle instability. All patient charts, x-rays, operative reports, and surgical videotapes were reviewed. A detailed questionnaire was answered by all patients. The study population included 31 males and 23 females, with a mean age of 31 years (range, 14–64 years). The right ankle was involved in 64% of cases. Average follow-up was 9.6 months. Arthroscopic surgery was performed using small joint instrumentation including 30° and 70° 2.7-mm arthroscopes and a 30° 1.9-mm arthroscope. At surgery, 51 ankles (93%) had intra-articular abnormalities including loose bodies (12), synovitis (38), osteochondral lesions of the talus (9), ossicles (14), osteophytes (6), adhesions (8), and chondromalacia (12). The most common arthroscopic procedures were synovectomy, removal of loose bodies and ossicles, excision and drilling of osteochondral lesions, debridement of the lateral gutter, excision of osteophytes, and removal of adhesions and scar tissue. There was a 25% incidence of chondral injuries, which differs considerably from the results of Taga et al., who found chondral injuries in 95% of ankles with lateral instability. Overall, there were excellent or good results in 96% of ankles. The incidence of excellent results was lower in the workers compensation patients because of a greater incidence of complaints of pain with activity. There was no correlation between the presence of osteochondral lesions or amount of talar tilt and results.

Chronic Lateral Instability: Arthroscopic Findings and Long-Term Results

Background: A wide variety of procedures have been described to treat chronic lateral ankle instability. Nonanatomic procedures sacrifice normal tissue and can restrict motion. Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments, supplemented by reefing of the exstensor retinaculum (modified Broström procedure) provides good long-term stability with minimal drawbacks. Methods: Twenty-one patients had arthroscopic evaluation followed by the Gould modification of the Broström procedure. All patients filled out a detailed questionnaire, including the American Orthopaedic Foot and Ankle Society Ankle/Hindfoot Score, Modified Weber Score, and Hamilton Score at an average of 60 months after surgery. All patients were re-examined, and 14 had stress radiographs for comparison with the preoperative films. Results: Ninety-five percent of the patients (20 of 21) had associated intra-articular problems. The mean score for the Modified Weber Score was 96; for the Ankle/Hindfoot Score, 97; and for the Hamilton score, 100% good and excellent results. All 14 patients recorded a side-to-side difference of less than 3 degrees on their postoperative stress radiographs. Conclusions: A high percentage of patients with lateral ankle instability have intra-articular pathology. Excellent results can be expected in patients with ankle instability who undergo arthroscopic treatment of associated intra-articular pathology and the modified Broström procedure.

Complications in foot and ankle arthroscopy.

Arthroscopy of the foot and ankle has become an important diagnostic and therapeutic tool for the orthopaedic surgeon. A thorough knowledge of foot and ankle anatomy and intraarticular anatomy is critical to avoid complications in foot and ankle arthroscopy. Numerous complications can occur in foot and ankle arthroscopy, such as neurologic, tendon, and ligament injuries, wound complications, infections, and instrument breakage. The most common complication is neurologic injury. The overall complication rate is 9%. Most complications associated with foot and ankle arthroscopy are transient and tend to resolve within 6 months. The only complication that persisted at 10 years followup was a neurologic injury, specifically, numbness at the incision site. Because the difficulty of procedures has increased, so has the complication rate. Knowledge of the more common complications in foot and ankle arthroscopy and improved techniques and instruments may reduce the overall complication rate.

Long-term results of arthroscopic ankle arthrodesis.

Background: More than 40 open procedures have been described for ankle arthrodesis, most with high complication rates. Since its description in 1983, arthroscopic ankle arthrodesis has become a viable option in selected patients. With one of the largest series in the literature, the purpose of the paper was to analyze the results of arthroscopic ankle arthrodesis at our institution. Methods: Between 1989 and 2002, 35 patients with end-stage ankle arthritis underwent arthroscopic ankle arthrodesis. The average followup was 72 months, with a range of 24 to 167 months. Patients returned for a clinical and radiolographic evaluation using the grading systems of Mazur and Morgan. All patients had preoperative and postoperative radiographic evaluation to assess fusion. Indications for arthroscopic ankle arthrodesis included failure of at least 6 months of conservative treatment, minimal or mild correctable deformity in the coronal plane, and no active infections. Results: The overall fusion rate was 97% (34 of 35 patients). The average time to fusion was 11.8 weeks, with a range of 8 to 18 weeks. There were 74% good to excellent results by the Mazur grading system and 83% by the Morgan system. There were no infections or neurovascular injuries. In the three patients who required bone stimulators for delayed unions, fusion occurred in two, and one had a nonunion. Eleven patients had screws removed because of pain at an average of 11 months after the initial surgery. Conclusion: Our study demonstrated a high fusion rate with minimal complications for arthroscopic ankle arthrodesis.

Progress in ankle arthroscopy.

Ankle arthroscopy is rapidly gaining in popularity as an important diagnostic and therapeutic procedure. Indications for this technique include pain, swelling, stiffness, instability, hemarthrosis, and locking of the ankle. The anteromedial, anterolateral, and posterolateral portals are most commonly used. The use of a short, 30 degrees oblique arthroscope, with an ankle holder and distractor, permits visualization of the entire joint. Operative treatment is facilitated by small joint shavers, burrs, knives, and baskets. Intraarticular problems such as chondromalacia, osteophytes, loose bodies, synovitis, osteoarthritis, fracture, and instability all can be addressed arthroscopically. Prior to this technique, the cause of chronic ankle pain was poorly understood. Now, lateral ankle impingement is a well-recognized entity that responds well to arthroscopic treatment. Ankle arthroscopy provides a safe, effective method of diagnosis and treatment with few complications. Further advances in equipment and technique should expand indications for this procedure.

Arthroscopic Excision of the Os Trigonum: A New Technique with Preliminary Clinical Results

Open excision of a painful os trigonum can be associated with prolonged recovery. An arthroscopic technique has been developed to decrease scarring, diminish surgical morbidity, and promote a faster recovery. Eleven patients were retrospectively evaluated after removal of the os trigonum after a mean follow-up of 35 months. Small joint arthroscopy equipment was utilized in a supine position with a distraction device. Average patient scores improved on the AOFAS Ankle/Hindfoot Scale from 45 to 86 points. All patients went home the same day, and no complications occurred during the procedure. All patients reached maximum recovery level within the first 3 months after surgery. Arthroscopic excision of a painful os trigonum yields good results with minimal surgical morbidity and shorter recovery time.