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Arthroscopy of the problematic total knee arthroplasty
ABSTRACTS
Delayed Articular Cartilage Slough: Two Cases Resulting From Inadvertent HO:YAG Laser Damage to Normal Articular Cartilage and a Review of the Literature. Marc B. Danziger, Raymond Thai, and Ann Kelly. Washington, D.C. and Reston, Virginia, U.S.A. Recent advances in laser technology have resulted in increasing use of lasers for standard arthroscopic procedures, especially in the knee. Reports on complications associated with the use of the Nd:YAG and Ho:YAG lasers have been few. We present two cases referred from other physicians with chondral damage and cartilage slough secondary to use of the Holmiun:YAG laser. The first patient is a 50 year old female who sustained a bucket handle tear of her lateral meniscus. At the time of arthroscopy, a partial lateral meniscectomy was done with a 20 watt Holmium:Yag laser. The patient never fully recovered, with persistent knee pain and swelling. The patient underwent a second arthroscopy 15 months later which revealed multiple large cartilaginous loose fragments dispersed throughout the joint. The lateral femoral condyle revealed large areas of partial and full thickness cartilage defects (Outerbridge Grade III and IV defects). The loose bodies were removed and the lateral femoral condyle was debrided using a motorized shaver. The second patient is a 35 year old female who underwent an arthroscopy in 1994 for a history of intermittent right knee pain. She was noted to have grade III changes of the lateral tibial plateau and undersurface of the patella, as well as a lateral meniscus tear, all of which were debrided with a Holmium:YAG laser. The lateral femoral condyle was noted to be normal. At four months postoperatively, the patient developed recurrent symptoms. Conservative treatment failed and a second arthroscopy was performed. Of significant note were new degenerative changes to the lateral femoral condyle which had been noted to be normal at the arthroscopy nine months prior. Large loose fragments of cartilage from the patella and femoral condyle were removed. The surgical benefits and issues of the increased cost of laser surgery remain in question. Retrospective studies by Fanton and Dillingham, Abelow, and Lane and colleagues have failed to show statistically significant advantages of the laser when compared to conventional arthroscopy. No prospective, randomized studies have been done. While cost effectiveness and surgical outcomes have been at the forefront of the laser debate, this study and another new report may make the debate irrelevant. At the AAOS meeting in
349
February 1995, Garino presented five cases of paraarticular osteonecrosis and subsequent cartilage defects in the knees of patients treated with a YAG laser during arthroscopy. We now present two cases of permanent damage incurred to otherwise healthy cartilage by the Ho:YAG laser. With no proven scientific benefit at improving patients outcome over conventional arthroscopy, an increased cost to the patient, and new reports of osteonecrosis and cartilage sloughing, it is difficult to endorse the laser as a useful adjunct to conventional arthroscopy. Rather, a careful look needs to be taken at its limited use until further randomized prospective studies are done comparing patient outcomes, cost, and long term complications.
Arthroscopy of the Problematic Total Knee Arthroplasty. David R. Diduch, Giles R. Scuderi, W. Norman Scott, Michael A. Kelly, and John N. Insall. New York, New York, U.S.A. Introduction: We evaluated the utility and safety of arthroscopy for diagnosing and treating symptoms in problematic total knee replacements. Methods: From 1988 to 1995, forty arthroscopies were performed on 38 patients with an average age of 68.4 years. The average onset of symptoms post knee replacement was 33.7 months (range 1 mo. to 15 yrs.), and the average duration of symptoms prior to arthroscopy was 15.6 months (range 1 mo. to 5 yrs.). Presenting symptoms included pain in 73%, catching or soft tissue impingement in 35%, and stiffness in 18% of patients. Our protocol involves 24 hours of perioperative, intravenous antibiotics, and two or three routine arthroscopic portals. There were no arthroscopically related complications or infections. Results: Arthroscopy successfully diagnosed the etiology of the patients' symptoms in all but one case. Operative diagnoses including impinging soft tissue under the patella consistent with the " c l u n k " syndrome (43%), impinging PCL stump (10%), impinging hypertrophic synovitis elsewhere in the knee (15%), prosthesis loosening or wear (10%), and arthrofibrosis (20%). Arthroscopic treatment consisted of removal of impinging tissue or loose body as indicated. Additionally, 8 of the patients had a manipulation under anesthesia with an average improvement in flexion of 26.3 degrees postoperatively. At an average follow up of 19.7 months (range 4 mos. to 6 yrs.), 28% of patients had developed recurrent symptoms. Two of these patients had repeat arthroscopy for recurrent impinging hypertrophic synovitis, and three patients underwent total knee revisions. The chances of successfully reArthroscop)', Vol 12, No 3, 1996
350
ABSTRACTS
lieving symptoms without recurrance according to operative diagnosis were 82% for "clunks", 60% for other impinging synovium or soft tissue, and 63% for arthrofibrosis. The average Knee Society ratings at follow up for the knee scores and the function scores respectively were 92.6 and 91.4 for group A patients, 91.0 and 88.0 for group B patients, and 80.5 and 76.2 for group C patients. In group A and group B, 100% of the knee and function Knee Society scores fell in the good or excellent range. For group C patients, 88% of knee scores and 82% of function scores were good or excellent. Conclusion: Arthroscopy successfully identified all cases of soft tissue impingement or prosthetic loosening or wear, and successfully treated 74% of patients with impinging soft tissue types of pain without recurrence. There were no arthroscopy associated complications or infections. Revision knee replacements were necessary in only 7.5% of cases, suggesting that the much less invasive arthroscopy may be helpful for avoiding revision in certain problematic knee replacements.
Independent Home Therapy Versus Formal Physical Therapy Following Arthroscopic Shoulder Surgery. Eugene M. Wolf Robert A. Gomez, and Diedre K. Paris. San Francisco, and Mission Viejo, California, U.S.A. This study was designed to examine the differences in both cost and postoperative results following arthroscopic shoulder surgery when patients were rehabilitated with either independent home therapy or formal physical therapy. Fifty consecutive postoperative arthroscopic shoulder surgery patients were randomly assigned to either an independent home therapy program or to receive formal physical therapy for postoperative rehabilitation. Home therapy patients received a home kit and were instructed in its use for daily exercises. Formal physical therapy patients were referred to various outside physical therapists for traditional rehabilitation programs. Telephone interviews were then used to apply a 20-point scale and each patient was assigned a postoperative score. The average home therapy and formal physical therapy scores were 16.8 and 14.4 respectively (P < .01). The average cost of the home therapy was $195 per patient versus $1,106 per patient for the formal physical therapy. In summary, the home therapy resulted in a net savings of $911 per patient with statistically significant Arthroscopy, Vol 12, No 3, 1996
better results. Since roughly 250,000 arthroscopic shoulder procedures are performed each year, the estimated potential yearly savings using home therapy approaches hundreds of millions of dollars.
Elbow Arthroscopy: A Review of Outcomes. Randy Jaeger, John F. Meyers, Terry L. Whipple, Richard B. Caspari, and William R. Beach. Allentown, Pennsylvania, and Richmond, and Glen Allen, Virginia, U.S.A. The purpose of this review is threefold: to assess the subjective and objective outcomes of elbow arthroscopy; to identify differences in outcome based on postoperative diagnosis; and to measure the accuracy of preoperative diagnoses. Forty-two (45 elbows) from a consecutive series of 65 patients were available for follow-up study. Twenty-two were examined by the authors and twenty were interviewed by telephone. Mean follow-up time from surgery was 2 years 10 months (range: 6 months to 5 years 3 months). The patients were asked to grade their post surgical improvement on a scale of 0%100%. The mean overall subjective improvement was 72% and 52% of patients cited a 90%-100% improvement. Fifteen patients were examined who had a preoperative flexion contracture. There was a mean gain of 10° of extension postoperatively. Ten patients with extension contractures were examined. They had a mean flexion gain of 14°. The results of mean subjective improvement correlated with diagnosis was as follows: synovitis 92%; loose bodies 78%; osteoarthritic spurs 72%; posttraumatic adhesions 47%. In only 20% of cases was the postoperative diagnosis significantly different than the preoperative diagnosis. From this study we concluded that the majority of patients had significant subjective improvement following elbow arthroscopy. Elbow arthroscopy yielded excellent and good results in treating synovitis, loose bodies, and osteoarthritic spurs, but only fair or poor results treating posttraumatic adhesions. Our preoperative diagnosis was substantiated in 80% of cases.
Infection Following Knee Arthroscopy in Joint Replacement Patients. Domenick J. Sisto and Debbie L. Cook. Sherman Oaks, California, U.S.A. A retrospective review to evaluate the infection rate and patient satisfaction in knee joint replacement patients who have undergone subsequent arthroscopic surgery was undertaken. Included in this group are patients who have undergone not only total knee arthroplasty (TKR), but patello-femoral joint replacement (PFR) and unicompartmental replacement, both
Delayed Articular Cartilage Slough: Two Cases Resulting From Inadvertent HO:YAG Laser Damage to Normal Articular Cartilage and a Review of the Literature. Marc B. Danziger, Raymond Thai, and Ann Kelly. Washington, D.C. and Reston, Virginia, U.S.A. Recent advances in laser technology have resulted in increasing use of lasers for standard arthroscopic procedures, especially in the knee. Reports on complications associated with the use of the Nd:YAG and Ho:YAG lasers have been few. We present two cases referred from other physicians with chondral damage and cartilage slough secondary to use of the Holmiun:YAG laser. The first patient is a 50 year old female who sustained a bucket handle tear of her lateral meniscus. At the time of arthroscopy, a partial lateral meniscectomy was done with a 20 watt Holmium:Yag laser. The patient never fully recovered, with persistent knee pain and swelling. The patient underwent a second arthroscopy 15 months later which revealed multiple large cartilaginous loose fragments dispersed throughout the joint. The lateral femoral condyle revealed large areas of partial and full thickness cartilage defects (Outerbridge Grade III and IV defects). The loose bodies were removed and the lateral femoral condyle was debrided using a motorized shaver. The second patient is a 35 year old female who underwent an arthroscopy in 1994 for a history of intermittent right knee pain. She was noted to have grade III changes of the lateral tibial plateau and undersurface of the patella, as well as a lateral meniscus tear, all of which were debrided with a Holmium:YAG laser. The lateral femoral condyle was noted to be normal. At four months postoperatively, the patient developed recurrent symptoms. Conservative treatment failed and a second arthroscopy was performed. Of significant note were new degenerative changes to the lateral femoral condyle which had been noted to be normal at the arthroscopy nine months prior. Large loose fragments of cartilage from the patella and femoral condyle were removed. The surgical benefits and issues of the increased cost of laser surgery remain in question. Retrospective studies by Fanton and Dillingham, Abelow, and Lane and colleagues have failed to show statistically significant advantages of the laser when compared to conventional arthroscopy. No prospective, randomized studies have been done. While cost effectiveness and surgical outcomes have been at the forefront of the laser debate, this study and another new report may make the debate irrelevant. At the AAOS meeting in
349
February 1995, Garino presented five cases of paraarticular osteonecrosis and subsequent cartilage defects in the knees of patients treated with a YAG laser during arthroscopy. We now present two cases of permanent damage incurred to otherwise healthy cartilage by the Ho:YAG laser. With no proven scientific benefit at improving patients outcome over conventional arthroscopy, an increased cost to the patient, and new reports of osteonecrosis and cartilage sloughing, it is difficult to endorse the laser as a useful adjunct to conventional arthroscopy. Rather, a careful look needs to be taken at its limited use until further randomized prospective studies are done comparing patient outcomes, cost, and long term complications.
Arthroscopy of the Problematic Total Knee Arthroplasty. David R. Diduch, Giles R. Scuderi, W. Norman Scott, Michael A. Kelly, and John N. Insall. New York, New York, U.S.A. Introduction: We evaluated the utility and safety of arthroscopy for diagnosing and treating symptoms in problematic total knee replacements. Methods: From 1988 to 1995, forty arthroscopies were performed on 38 patients with an average age of 68.4 years. The average onset of symptoms post knee replacement was 33.7 months (range 1 mo. to 15 yrs.), and the average duration of symptoms prior to arthroscopy was 15.6 months (range 1 mo. to 5 yrs.). Presenting symptoms included pain in 73%, catching or soft tissue impingement in 35%, and stiffness in 18% of patients. Our protocol involves 24 hours of perioperative, intravenous antibiotics, and two or three routine arthroscopic portals. There were no arthroscopically related complications or infections. Results: Arthroscopy successfully diagnosed the etiology of the patients' symptoms in all but one case. Operative diagnoses including impinging soft tissue under the patella consistent with the " c l u n k " syndrome (43%), impinging PCL stump (10%), impinging hypertrophic synovitis elsewhere in the knee (15%), prosthesis loosening or wear (10%), and arthrofibrosis (20%). Arthroscopic treatment consisted of removal of impinging tissue or loose body as indicated. Additionally, 8 of the patients had a manipulation under anesthesia with an average improvement in flexion of 26.3 degrees postoperatively. At an average follow up of 19.7 months (range 4 mos. to 6 yrs.), 28% of patients had developed recurrent symptoms. Two of these patients had repeat arthroscopy for recurrent impinging hypertrophic synovitis, and three patients underwent total knee revisions. The chances of successfully reArthroscop)', Vol 12, No 3, 1996
350
ABSTRACTS
lieving symptoms without recurrance according to operative diagnosis were 82% for "clunks", 60% for other impinging synovium or soft tissue, and 63% for arthrofibrosis. The average Knee Society ratings at follow up for the knee scores and the function scores respectively were 92.6 and 91.4 for group A patients, 91.0 and 88.0 for group B patients, and 80.5 and 76.2 for group C patients. In group A and group B, 100% of the knee and function Knee Society scores fell in the good or excellent range. For group C patients, 88% of knee scores and 82% of function scores were good or excellent. Conclusion: Arthroscopy successfully identified all cases of soft tissue impingement or prosthetic loosening or wear, and successfully treated 74% of patients with impinging soft tissue types of pain without recurrence. There were no arthroscopy associated complications or infections. Revision knee replacements were necessary in only 7.5% of cases, suggesting that the much less invasive arthroscopy may be helpful for avoiding revision in certain problematic knee replacements.
Independent Home Therapy Versus Formal Physical Therapy Following Arthroscopic Shoulder Surgery. Eugene M. Wolf Robert A. Gomez, and Diedre K. Paris. San Francisco, and Mission Viejo, California, U.S.A. This study was designed to examine the differences in both cost and postoperative results following arthroscopic shoulder surgery when patients were rehabilitated with either independent home therapy or formal physical therapy. Fifty consecutive postoperative arthroscopic shoulder surgery patients were randomly assigned to either an independent home therapy program or to receive formal physical therapy for postoperative rehabilitation. Home therapy patients received a home kit and were instructed in its use for daily exercises. Formal physical therapy patients were referred to various outside physical therapists for traditional rehabilitation programs. Telephone interviews were then used to apply a 20-point scale and each patient was assigned a postoperative score. The average home therapy and formal physical therapy scores were 16.8 and 14.4 respectively (P < .01). The average cost of the home therapy was $195 per patient versus $1,106 per patient for the formal physical therapy. In summary, the home therapy resulted in a net savings of $911 per patient with statistically significant Arthroscopy, Vol 12, No 3, 1996
better results. Since roughly 250,000 arthroscopic shoulder procedures are performed each year, the estimated potential yearly savings using home therapy approaches hundreds of millions of dollars.
Elbow Arthroscopy: A Review of Outcomes. Randy Jaeger, John F. Meyers, Terry L. Whipple, Richard B. Caspari, and William R. Beach. Allentown, Pennsylvania, and Richmond, and Glen Allen, Virginia, U.S.A. The purpose of this review is threefold: to assess the subjective and objective outcomes of elbow arthroscopy; to identify differences in outcome based on postoperative diagnosis; and to measure the accuracy of preoperative diagnoses. Forty-two (45 elbows) from a consecutive series of 65 patients were available for follow-up study. Twenty-two were examined by the authors and twenty were interviewed by telephone. Mean follow-up time from surgery was 2 years 10 months (range: 6 months to 5 years 3 months). The patients were asked to grade their post surgical improvement on a scale of 0%100%. The mean overall subjective improvement was 72% and 52% of patients cited a 90%-100% improvement. Fifteen patients were examined who had a preoperative flexion contracture. There was a mean gain of 10° of extension postoperatively. Ten patients with extension contractures were examined. They had a mean flexion gain of 14°. The results of mean subjective improvement correlated with diagnosis was as follows: synovitis 92%; loose bodies 78%; osteoarthritic spurs 72%; posttraumatic adhesions 47%. In only 20% of cases was the postoperative diagnosis significantly different than the preoperative diagnosis. From this study we concluded that the majority of patients had significant subjective improvement following elbow arthroscopy. Elbow arthroscopy yielded excellent and good results in treating synovitis, loose bodies, and osteoarthritic spurs, but only fair or poor results treating posttraumatic adhesions. Our preoperative diagnosis was substantiated in 80% of cases.
Infection Following Knee Arthroscopy in Joint Replacement Patients. Domenick J. Sisto and Debbie L. Cook. Sherman Oaks, California, U.S.A. A retrospective review to evaluate the infection rate and patient satisfaction in knee joint replacement patients who have undergone subsequent arthroscopic surgery was undertaken. Included in this group are patients who have undergone not only total knee arthroplasty (TKR), but patello-femoral joint replacement (PFR) and unicompartmental replacement, both