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Arthroscopic treatment of transchondral talar dome fractures
140
ABSTRACTS MINIPAPERS
Arthroscopy of Total Knee Replacements. A Preliminary Report. Don Johnson, John B. McGinty, J. Lorin Mason, Jr., and Edward St. Mary. Charleston, South Carolina, U.S.A. Our objective was to evaluate the role of diagnostic arthroscopy and arthroscopic surgery in the evaluation and treatment of painful total knee replacements (TKR). A r t h r o s c o p y of a T K R can demonstrate pathology not evident clinically or radiographically and can successfully treat some causes of painful TKR, thus avoiding a more extensive arthrotomy. Arthroscopy is another diagnostic tool for evaluating and treating painful TKR. There is less morbidity, the rehabilitation time is decreased, and any further surgery is not compromised. Fourteen patients with painful TKR were evaluated clinically, radiographically, and diagnostically to rule out loosening or infection. When conservative t h e r a p y failed to improve the p a t i e n t s ' symptoms, an arthroscopy was performed. This was performed with prophylactic antibiotic coverage and strict aseptic technique. Care was taken not to damage the polyethylene or scratch the metal components. The following procedures were performed arthroscopically to treat what was thought to be the cause of the patients' symptoms: lateral release for subluxating patella; lysis of dense intraarticular adhesions; removal of loose bodies (methacrylate); removal of pseudomeniscus impinging between the femoral and tibial components and causing subluxation. Postoperative rehabilitation is extremely important, and most patients improved postoperatively, but one subsequently required a revision TKR. The remaining 13 patients were symptom free at a mean follow-up of 1 year. Because a more extensive arthrotomy is avoided, the morbidity is markedly decreased and the patient is able to be rehabilitated more quickly. This technique does not prevent future arthrotomy and/ or revision surgery.
The Effects of Nd:YAG Laser in Arthroscopic Surgery of the Knee Meniscus. Jan Fronek, Gary J. Kelman, and Clifford W. Colwell. La Jolla, California, U.S.A. The use of laser energy for arthroscopic surgery of the meniscus has been fraught with difficult problems, including excessive tissue penetration Arthroscopy, VoL 4, No. 2, 1988
and the need for a gas medium. The use of the neodymium: yttrium aluminum garnet (Nd:YAG) laser provides better control of the penetration depth as well as the opportunity to operate in liquid medium. Twenty excised menisci and twenty cadaver knee menisci were exposed to contact laser radiation of a single power density at 1.064 txm. The operating parameters were a power level of 5-45 W and exposure time of 0.2 to 5.0 s. The meniscus was monitored by direct visualization and needle temperature probe. All samples were embedded, sectioned in plane perpendicular to the beam, and assessed for carbonized debris, cavitation, and chondrocyte necrosis. The laser-induced dissection yielded reproducible layers of cavitation and necrosis, proportional to the power and duration of the beam. At 40 W of power for 2 s, the cavitation layer is 0.5-1.0 mm and the surrounding necrosis is 0.2-0.7 mm, as defined by the disruption and disorganization of the collagen fibrils and chondrocyte nuclei. The carbonized debris was noted on the edge of the cut surface, particularly at the higher power settings. This material was easily brushed off with a blunt probe and irrigated out of the knee joint. The meniscus temperature 2 mm from the focus of the beam was not increased significantly. The Nd:YAG laser has been observed to section the meniscus cartilage in a very controlled, safe, and accurate fashion. For the best tissue effect, beam impulses of 30-40 W applied for 2-4 s offer the most efficacious combination for the knee menisectomy. Although these findings are very promising for the clinical utilization of the Nd:YAG laser in arthroscopic surgery, it is clear that more detailed studies of the tissue in an animal model are required.
Arthroscopic Treatment of Transchondral Talar Dome Fractures. Kent Van Beucken, Robert L. Barrack, and A. Herbert Alexander. Oakland, California, U.S.A. Fifteen cases of transchondral talar dome fractures treated arthroscopically between January 1984 and July 1985 were reviewed. Minimum 18month clinical follow-up was required for inclusion in the study. Radiographs and clinical examinations were performed preoperatively and from 18-36 months postoperatively (mean, 26 months). Patients were classified as excellent (asymptomatic),
ABSTRACTS good (occasional nondisabling pain only), fair (occasional disabling pain, improved from preoperatively), and poor (no improvement). Preoperatively, 11 patients had constant disabling pain and four had occasional disabling pain. There were ten male and five female patients with a mean age of 23 (range, 14-31 years). There was a discrete traumatic episode in 14 of 15. The average interval from injury to surgery was 11 months (range, 1 week to 48 months). Nine lesions were anterolateral and five were posteromedial. Six were Berndt and Harty Stage IV, eight were Stage III, and one was Stage II. All were treated by arthroscopic excision of the fragment and abrasion and/or drilling of the remaining crater. Only anterior portals were used. Early motion was started postoperatively but weight-bearing was delayed for 2 - 3 months. Results were: nine excellent, four good, one fair, and one poor. The poor result was one of only two lesions I> 1.5 cm wide. The other lesion of that size, however, was an excellent result. No correlation was seen between clinical result and location of lesion (medial or lateral), radiographic stage, or time from injury to surgery. There were no operative complications. Results of arthroscopic treatment compare favorably with those of open arthrotomy. Arthroscopic Patellar Realignment. David A. Detrisac, Michael D. Austin, and Lanny L. Johnson. East Lansing, Michigan, U.S.A. Arthroscopic patellar realignment is a new procedure that corrects patellar malalignment. The surgical procedure consists of an arthroscopic lateral release and arthroscopic medial capsular imbrication. The major advantage of this arthroscopic technique is viewing of patellar tracking, which allows documentation of the presence and magnitude of the malalignment before surgical correction. The effectiveness of the surgical correction is also monitored. Since 1980, 77 arthroscopic patellar realignments with at least 1 year of follow-up have been performed by us. The average follow-up was 39.1 months. There were 31 men and 42 women. (Four procedures were bilateral.) The operative knees were assessed for recurrence of patellar instability, pain,, stiffness, and flmctional limitations. Eighty percent had no recurrence of patellar instability. Thirteen percent had occasional feelings of giving way, which may represent patellar subluxation.
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Seven percent had postoperative patellar dislocation. Five and three-tenths percent had further surgical treatment of the patellar instability. Of the patients with postoperative patellar dislocations, 80% had patella alta. In this series, 30% had no knee pain whereas 50% had occasional pain without any limitations of activities. The knee pain at follow-up appeared to be related to the degree of chondromalacia of the patella or femoral trochlea at the time of the arthroscopic patellar realignment. For the patient with recurrent patella subluxation and dislocation without patella alta, arthroscopie patellar realignment for recurrent patellar subluxation or dislocation has proven to be an effective treatment method. A Simple Approach to Hip Arthroscopy. Henri Dorfmann, Th. Boyer, P. Henry, and B. De Bie. Paris, France. For discussion purposes with respect to arthroscopy, the hip can be divided into two zones: superficial (synovium, neck, labrum, and two-thirds of the surface and circumference of the femoral head) and deep (acetabulum and remainder of the femoral articular surface). After cadaveric study, an anterolateral arthroscopic approach was devised. The technique is effective and convenient. No fracture table nor x-ray control is used, and no attempt is made to distract the femoral head from the acetabulum. Osseous landmarks are drawn. A spinal needle is inserted midway on a line connecting the anterosuperior iliac spine and the anterosuperior corner of the greater trochanter. The needle is directed toward the center of the femoral head. On piercing the hip capsule, 30 ml of irrigating solution is injected. An arthroscope sheath and trochar are then inserted along the same pathway as the needle. If necessary, a second entry is made - 4 cm distal to the first. Only the superficial zone described above may be so explored. This is sufficient for most diagnostic and therapeutic purposes to date, acknowledging that one-third of the femoral head cannot be seen. A few conditions of the hip require visual inspection of the acetabulum for diagnosis. Since January 1983 we have performed 60 hip arthroscopies successfully using this technique. Diagnosis in this series has included coxarthrosis (15), coxitis (nine), PVS (four), isolated labrum rupture (three), and miscellaneous (four). Ten hips were Arthroscopy, Vol. 4, No, 2, 1988
ABSTRACTS MINIPAPERS
Arthroscopy of Total Knee Replacements. A Preliminary Report. Don Johnson, John B. McGinty, J. Lorin Mason, Jr., and Edward St. Mary. Charleston, South Carolina, U.S.A. Our objective was to evaluate the role of diagnostic arthroscopy and arthroscopic surgery in the evaluation and treatment of painful total knee replacements (TKR). A r t h r o s c o p y of a T K R can demonstrate pathology not evident clinically or radiographically and can successfully treat some causes of painful TKR, thus avoiding a more extensive arthrotomy. Arthroscopy is another diagnostic tool for evaluating and treating painful TKR. There is less morbidity, the rehabilitation time is decreased, and any further surgery is not compromised. Fourteen patients with painful TKR were evaluated clinically, radiographically, and diagnostically to rule out loosening or infection. When conservative t h e r a p y failed to improve the p a t i e n t s ' symptoms, an arthroscopy was performed. This was performed with prophylactic antibiotic coverage and strict aseptic technique. Care was taken not to damage the polyethylene or scratch the metal components. The following procedures were performed arthroscopically to treat what was thought to be the cause of the patients' symptoms: lateral release for subluxating patella; lysis of dense intraarticular adhesions; removal of loose bodies (methacrylate); removal of pseudomeniscus impinging between the femoral and tibial components and causing subluxation. Postoperative rehabilitation is extremely important, and most patients improved postoperatively, but one subsequently required a revision TKR. The remaining 13 patients were symptom free at a mean follow-up of 1 year. Because a more extensive arthrotomy is avoided, the morbidity is markedly decreased and the patient is able to be rehabilitated more quickly. This technique does not prevent future arthrotomy and/ or revision surgery.
The Effects of Nd:YAG Laser in Arthroscopic Surgery of the Knee Meniscus. Jan Fronek, Gary J. Kelman, and Clifford W. Colwell. La Jolla, California, U.S.A. The use of laser energy for arthroscopic surgery of the meniscus has been fraught with difficult problems, including excessive tissue penetration Arthroscopy, VoL 4, No. 2, 1988
and the need for a gas medium. The use of the neodymium: yttrium aluminum garnet (Nd:YAG) laser provides better control of the penetration depth as well as the opportunity to operate in liquid medium. Twenty excised menisci and twenty cadaver knee menisci were exposed to contact laser radiation of a single power density at 1.064 txm. The operating parameters were a power level of 5-45 W and exposure time of 0.2 to 5.0 s. The meniscus was monitored by direct visualization and needle temperature probe. All samples were embedded, sectioned in plane perpendicular to the beam, and assessed for carbonized debris, cavitation, and chondrocyte necrosis. The laser-induced dissection yielded reproducible layers of cavitation and necrosis, proportional to the power and duration of the beam. At 40 W of power for 2 s, the cavitation layer is 0.5-1.0 mm and the surrounding necrosis is 0.2-0.7 mm, as defined by the disruption and disorganization of the collagen fibrils and chondrocyte nuclei. The carbonized debris was noted on the edge of the cut surface, particularly at the higher power settings. This material was easily brushed off with a blunt probe and irrigated out of the knee joint. The meniscus temperature 2 mm from the focus of the beam was not increased significantly. The Nd:YAG laser has been observed to section the meniscus cartilage in a very controlled, safe, and accurate fashion. For the best tissue effect, beam impulses of 30-40 W applied for 2-4 s offer the most efficacious combination for the knee menisectomy. Although these findings are very promising for the clinical utilization of the Nd:YAG laser in arthroscopic surgery, it is clear that more detailed studies of the tissue in an animal model are required.
Arthroscopic Treatment of Transchondral Talar Dome Fractures. Kent Van Beucken, Robert L. Barrack, and A. Herbert Alexander. Oakland, California, U.S.A. Fifteen cases of transchondral talar dome fractures treated arthroscopically between January 1984 and July 1985 were reviewed. Minimum 18month clinical follow-up was required for inclusion in the study. Radiographs and clinical examinations were performed preoperatively and from 18-36 months postoperatively (mean, 26 months). Patients were classified as excellent (asymptomatic),
ABSTRACTS good (occasional nondisabling pain only), fair (occasional disabling pain, improved from preoperatively), and poor (no improvement). Preoperatively, 11 patients had constant disabling pain and four had occasional disabling pain. There were ten male and five female patients with a mean age of 23 (range, 14-31 years). There was a discrete traumatic episode in 14 of 15. The average interval from injury to surgery was 11 months (range, 1 week to 48 months). Nine lesions were anterolateral and five were posteromedial. Six were Berndt and Harty Stage IV, eight were Stage III, and one was Stage II. All were treated by arthroscopic excision of the fragment and abrasion and/or drilling of the remaining crater. Only anterior portals were used. Early motion was started postoperatively but weight-bearing was delayed for 2 - 3 months. Results were: nine excellent, four good, one fair, and one poor. The poor result was one of only two lesions I> 1.5 cm wide. The other lesion of that size, however, was an excellent result. No correlation was seen between clinical result and location of lesion (medial or lateral), radiographic stage, or time from injury to surgery. There were no operative complications. Results of arthroscopic treatment compare favorably with those of open arthrotomy. Arthroscopic Patellar Realignment. David A. Detrisac, Michael D. Austin, and Lanny L. Johnson. East Lansing, Michigan, U.S.A. Arthroscopic patellar realignment is a new procedure that corrects patellar malalignment. The surgical procedure consists of an arthroscopic lateral release and arthroscopic medial capsular imbrication. The major advantage of this arthroscopic technique is viewing of patellar tracking, which allows documentation of the presence and magnitude of the malalignment before surgical correction. The effectiveness of the surgical correction is also monitored. Since 1980, 77 arthroscopic patellar realignments with at least 1 year of follow-up have been performed by us. The average follow-up was 39.1 months. There were 31 men and 42 women. (Four procedures were bilateral.) The operative knees were assessed for recurrence of patellar instability, pain,, stiffness, and flmctional limitations. Eighty percent had no recurrence of patellar instability. Thirteen percent had occasional feelings of giving way, which may represent patellar subluxation.
141
Seven percent had postoperative patellar dislocation. Five and three-tenths percent had further surgical treatment of the patellar instability. Of the patients with postoperative patellar dislocations, 80% had patella alta. In this series, 30% had no knee pain whereas 50% had occasional pain without any limitations of activities. The knee pain at follow-up appeared to be related to the degree of chondromalacia of the patella or femoral trochlea at the time of the arthroscopic patellar realignment. For the patient with recurrent patella subluxation and dislocation without patella alta, arthroscopie patellar realignment for recurrent patellar subluxation or dislocation has proven to be an effective treatment method. A Simple Approach to Hip Arthroscopy. Henri Dorfmann, Th. Boyer, P. Henry, and B. De Bie. Paris, France. For discussion purposes with respect to arthroscopy, the hip can be divided into two zones: superficial (synovium, neck, labrum, and two-thirds of the surface and circumference of the femoral head) and deep (acetabulum and remainder of the femoral articular surface). After cadaveric study, an anterolateral arthroscopic approach was devised. The technique is effective and convenient. No fracture table nor x-ray control is used, and no attempt is made to distract the femoral head from the acetabulum. Osseous landmarks are drawn. A spinal needle is inserted midway on a line connecting the anterosuperior iliac spine and the anterosuperior corner of the greater trochanter. The needle is directed toward the center of the femoral head. On piercing the hip capsule, 30 ml of irrigating solution is injected. An arthroscope sheath and trochar are then inserted along the same pathway as the needle. If necessary, a second entry is made - 4 cm distal to the first. Only the superficial zone described above may be so explored. This is sufficient for most diagnostic and therapeutic purposes to date, acknowledging that one-third of the femoral head cannot be seen. A few conditions of the hip require visual inspection of the acetabulum for diagnosis. Since January 1983 we have performed 60 hip arthroscopies successfully using this technique. Diagnosis in this series has included coxarthrosis (15), coxitis (nine), PVS (four), isolated labrum rupture (three), and miscellaneous (four). Ten hips were Arthroscopy, Vol. 4, No, 2, 1988