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Indications and limitations of arthroscopic diagnosis of old lateral ligamentous ruptures of the ankle
ABSTRACTS
trinsic and extrinsic repair, confirmed by histological investigations. Arthroscopic Technique by a New Calcaneal PinTraction Device. Yusuo Kumaba, Yoshimori Shibata, Genzaburo Nishi, Satoshi Hattori, Toshiharu Okuda, and Takashi Ztoh. Aichi (YK, YS, GN, SH,
TO) and Nagoya (TI), Japan. In arthroscopic diagnostics, ease of manipulation of the scope within the joint space allows a wider view and hence a more precise diagnosis. For ankle, the main difftculties or arthroscopy arise from the narrowness of the joint space; limitation of the size of the scope to be used and restriction of its movement in the joint space often result in observations being inadequate. Some method to widen the joint space would improve the diagnostic capability of the arthroscopic technique. For this reason, we devised a pin-traction instrument that makes hand inversion-eversion, pronationsupination, and traction of the calcaneus relatively easy. The width of the joint space of the ankle (intact or amputated limb) in various positions was measured on frontal x-ray films. Then our device was fixed to the calcaneus of an amputated limb, and the enlarged joint space under various strengths of traction force was measured similarly on x-ray films. The widest joint space was obtained in the equinus position. By the use of the device, the space could be easily enlarged by simple manual traction. Injury to the cartilage during the operation of the arthroscope was decreased and much wider views were obtained by operation of the scope within the joint space, which seemed promising for improvement of diagnosis. Treatment for Intermediate Stage of Osteoarthritis of the Ankle Joint Based on Arthroscopic Examination. Yoshinori Takakura, Syunji Shiomi, Masataka Shimaya, Kazuya Sugimoto, Kenji Masuhara. Nara,
Japan. It is difficult to decide the indications for operative treatments for intermediate stage of osteoarthritis of the ankle joint. Therefore, treatment should be decided based on arthroscopic findings made before operation. Valgus wedge osteotomy was performed at the lower part of the tibia, if the remainder of the joint cartilage at the lateral side was confirmed in the ankle joint to have vat-us tilt
and an anterior of the tibia1 joint surface. This osteotomy was done in 10 women for a total of 10 ankles. Ligamentous repair was performed on one unstable joint with the joint cartilage on the whole. Two arthrodeses and one total replacement were performed on three ankles in which the joint cartilage had disappeared. To date, results have been good. On arthroscopic examination at 1 year after surgery, fibrous cartilage has covered on the part of the joint surface from which the cartilage had disappeared. Arthroscopic examination is useful for decision about operative indications and helpful in the making of a prognosis for osteoarthritis of the ankle joint. Chondral Lesions in the Unstable Ankle Secondary to the Chronic Lateral Ligament Injury: An Arthroscopic Study. Zchiro Taga, Konsei Shino, Masahiro Znoue, Akira Maeda, Keiro Ono. Osaka, Japan. In some cases of chronic lateral ligamentous injury of the ankle without obvious arthritic changes, ankle joint pain persists even if the joint is adequately stabilized by reconstruction of the ligament. Because of this problem, we examined arthroscopically nine cases of chronic unstable ankle, focusing on the chondral changes of the articular surfaces. Chondral lesions were found in all of the cases, most frequently in the anteromedial tibia1 plafond. These findings indicate the need for early stabilization of unstable ankles, especially for athletes. Indications and Limitations of Arthroscopic Diagnosis of Old Lateral Ligamentous Ruptures of the Ankle. Shigeyuki Hamada, Hitoshi Hirose, Znoue, and Teruo Doi. Osaka, Japan.
Yoshinori
We examined 1I patients with old lateral ligamentous ruptures of the ankle, mainly of the anterior talo-fibular ligament (ATFL), from the arthroscopic, operative, and histological standpoints. We also summarized arthroscopic findings for normal ATFLs. The purpose of this study was to make clear the problems and limitations of arthroscopic diagnosis of an old rupture of the lateral ligament of the ankle, and to describe the histological characteristics of injured ATFLs. Of the 11 patients, the ATFL could be identified arthroscopically in six. The six cases could be divided into two groups, one in which it was possible to diagnose the old rupture of the ATFL arthroscopically (in three patients), and the other in which arthroscopic findings for the Arthroscopy.
Vol. 7, No. 4, 1991
398
ABSTRACTS
ATFL were normal (in three). The five patients in whom the ATFL could not be identified arthroscopically were also divided into two groups. In one (with four patients), the ATFL was covered with proliferative and edematous synovia, so it was not identified arthroscopically. In the other group (with one patient), the ATFL had ruptured and disappeared, so that it was not identified arthroscopically. We concluded that the ATFL with an old rupture is identified arthroscopically only with difficulty because of its being covered with proliferative synovia. Operative findings in all cases but one were of continuity in appearance and severe fibrous changes of the ATFL. Even when the ATFL was normal in appearance arthroscopically, these same changes were present. Thus there was much difference between the arthroscopic and the operative findings, because the former were made from observations on the inside, and the latter from the outside. Histological study of the ATFL gave a definitive diagnosis of old rupture of the ATFL in all cases. Even when the arthroscopic findings were normal, the histological ones were that the ATFL tissue were replaced by fibrous scar tissue at the region of the rupture, irregularity of the collagen fibers and infiltration by fatty tissue were observed. Ankle arthroscopy is useful only as a supplemental means for the diagnosis of old ruptured lateral ligaments of the ankle, and an overall evaluation is needed as well. Introduction of the Arthroscope by Using Ultrasound. Shigeo Suzuki, Yoshitake Kasahara, mai, and Tooru Futami.
Makoto Ko-
Arthroscopic examination of the hip, shoulder, and ankle joint is sometimes difficult, because large muscles surround the joints and space for the arthroscope is limited. In September 1987, we used ultrasound for the introduction of the arthroscope into the hip joint for the first time. Later, arthroscopic examination of the shoulder (one case), the ankle (two cases), the knee (one case), and the hip joint (18 cases) were done by the use of ultrasound. Examinations by ultrasound were done with a Shimazu SDU-500 apparatus at 5.0 or 7.5 MHz, based on a linear electronic scanning method. Sagittal sections of the tissue were imaged on the screen and the needle was inserted into the joint Arthroscopy,
Vol. 7. No. 4, 1991
capsule. The image of the needle was readily seen by ultrasound. The joint was filled with saline, and then the trocar of the arthroscope was introduced into the joint with monitoring of the image of the trocar on the screen. When the synovial tissue of the hip joint was examined, the scope was inserted in the neck of the femur by an anterior approach. The joint surface was examined by a lateral approach with the patient on a traction table. Tumors or tumorous conditions could be imaged without difficulty, and the scope was inserted into the space close to the tumor. In the shoulder joint, the space between the head and acetabulum could be opened by the injection of saline. The bulging of the joint capsule made the introduction of the scope easy. In the ankle joint, the joint space between the tibia and the talus could be seen by plantal flexion. Posterior parts of the knee joint such as the posterior cruciate ligament or posterior horn of the meniscus were examined safely by the use of ultrasound, blood vessels were observed on the screen and the rear space was opened enough for introduction of the scope by the injection of saline. We succeeded in introducing the scope into 22 of the 24 joints with this method. Causes of failure were stiffness of the joint and insufficient capsule swelling. Our method can be called an objectoriented approach, for the scope is inserted close to the tissue to be examined. This is a relatively safe procedure because the blood vessels were imaged and there was no exposure to radiation. Trial of Arthroscopic Evaluation of Osteoarthritis of the Knee by Image Processing. Hirotaka Zguchi, Nobuo Matsui, Yoichi Taneda, Takashi Zto, and Sumikazu Tsuboguchi. Nagaya, Japan.
Arthroscopic images often cannot be used because of their bad focus or bad illumination. Another problem is turbidity of the irrigating fluid caused by bleeding, etc. Also, there is no way to make quantitative measurements in the arthroscopic evaluation of cartilage degeneration in osteoarthritis. To solve these problems, we developed a way to clarify such images and to establish a scale for the evaluation of degeneration by the use of image processing. Methods Five arthroscopic photographs (Fig. 2) were digitized with a photo-encoder (Photovics, Tamron
trinsic and extrinsic repair, confirmed by histological investigations. Arthroscopic Technique by a New Calcaneal PinTraction Device. Yusuo Kumaba, Yoshimori Shibata, Genzaburo Nishi, Satoshi Hattori, Toshiharu Okuda, and Takashi Ztoh. Aichi (YK, YS, GN, SH,
TO) and Nagoya (TI), Japan. In arthroscopic diagnostics, ease of manipulation of the scope within the joint space allows a wider view and hence a more precise diagnosis. For ankle, the main difftculties or arthroscopy arise from the narrowness of the joint space; limitation of the size of the scope to be used and restriction of its movement in the joint space often result in observations being inadequate. Some method to widen the joint space would improve the diagnostic capability of the arthroscopic technique. For this reason, we devised a pin-traction instrument that makes hand inversion-eversion, pronationsupination, and traction of the calcaneus relatively easy. The width of the joint space of the ankle (intact or amputated limb) in various positions was measured on frontal x-ray films. Then our device was fixed to the calcaneus of an amputated limb, and the enlarged joint space under various strengths of traction force was measured similarly on x-ray films. The widest joint space was obtained in the equinus position. By the use of the device, the space could be easily enlarged by simple manual traction. Injury to the cartilage during the operation of the arthroscope was decreased and much wider views were obtained by operation of the scope within the joint space, which seemed promising for improvement of diagnosis. Treatment for Intermediate Stage of Osteoarthritis of the Ankle Joint Based on Arthroscopic Examination. Yoshinori Takakura, Syunji Shiomi, Masataka Shimaya, Kazuya Sugimoto, Kenji Masuhara. Nara,
Japan. It is difficult to decide the indications for operative treatments for intermediate stage of osteoarthritis of the ankle joint. Therefore, treatment should be decided based on arthroscopic findings made before operation. Valgus wedge osteotomy was performed at the lower part of the tibia, if the remainder of the joint cartilage at the lateral side was confirmed in the ankle joint to have vat-us tilt
and an anterior of the tibia1 joint surface. This osteotomy was done in 10 women for a total of 10 ankles. Ligamentous repair was performed on one unstable joint with the joint cartilage on the whole. Two arthrodeses and one total replacement were performed on three ankles in which the joint cartilage had disappeared. To date, results have been good. On arthroscopic examination at 1 year after surgery, fibrous cartilage has covered on the part of the joint surface from which the cartilage had disappeared. Arthroscopic examination is useful for decision about operative indications and helpful in the making of a prognosis for osteoarthritis of the ankle joint. Chondral Lesions in the Unstable Ankle Secondary to the Chronic Lateral Ligament Injury: An Arthroscopic Study. Zchiro Taga, Konsei Shino, Masahiro Znoue, Akira Maeda, Keiro Ono. Osaka, Japan. In some cases of chronic lateral ligamentous injury of the ankle without obvious arthritic changes, ankle joint pain persists even if the joint is adequately stabilized by reconstruction of the ligament. Because of this problem, we examined arthroscopically nine cases of chronic unstable ankle, focusing on the chondral changes of the articular surfaces. Chondral lesions were found in all of the cases, most frequently in the anteromedial tibia1 plafond. These findings indicate the need for early stabilization of unstable ankles, especially for athletes. Indications and Limitations of Arthroscopic Diagnosis of Old Lateral Ligamentous Ruptures of the Ankle. Shigeyuki Hamada, Hitoshi Hirose, Znoue, and Teruo Doi. Osaka, Japan.
Yoshinori
We examined 1I patients with old lateral ligamentous ruptures of the ankle, mainly of the anterior talo-fibular ligament (ATFL), from the arthroscopic, operative, and histological standpoints. We also summarized arthroscopic findings for normal ATFLs. The purpose of this study was to make clear the problems and limitations of arthroscopic diagnosis of an old rupture of the lateral ligament of the ankle, and to describe the histological characteristics of injured ATFLs. Of the 11 patients, the ATFL could be identified arthroscopically in six. The six cases could be divided into two groups, one in which it was possible to diagnose the old rupture of the ATFL arthroscopically (in three patients), and the other in which arthroscopic findings for the Arthroscopy.
Vol. 7, No. 4, 1991
398
ABSTRACTS
ATFL were normal (in three). The five patients in whom the ATFL could not be identified arthroscopically were also divided into two groups. In one (with four patients), the ATFL was covered with proliferative and edematous synovia, so it was not identified arthroscopically. In the other group (with one patient), the ATFL had ruptured and disappeared, so that it was not identified arthroscopically. We concluded that the ATFL with an old rupture is identified arthroscopically only with difficulty because of its being covered with proliferative synovia. Operative findings in all cases but one were of continuity in appearance and severe fibrous changes of the ATFL. Even when the ATFL was normal in appearance arthroscopically, these same changes were present. Thus there was much difference between the arthroscopic and the operative findings, because the former were made from observations on the inside, and the latter from the outside. Histological study of the ATFL gave a definitive diagnosis of old rupture of the ATFL in all cases. Even when the arthroscopic findings were normal, the histological ones were that the ATFL tissue were replaced by fibrous scar tissue at the region of the rupture, irregularity of the collagen fibers and infiltration by fatty tissue were observed. Ankle arthroscopy is useful only as a supplemental means for the diagnosis of old ruptured lateral ligaments of the ankle, and an overall evaluation is needed as well. Introduction of the Arthroscope by Using Ultrasound. Shigeo Suzuki, Yoshitake Kasahara, mai, and Tooru Futami.
Makoto Ko-
Arthroscopic examination of the hip, shoulder, and ankle joint is sometimes difficult, because large muscles surround the joints and space for the arthroscope is limited. In September 1987, we used ultrasound for the introduction of the arthroscope into the hip joint for the first time. Later, arthroscopic examination of the shoulder (one case), the ankle (two cases), the knee (one case), and the hip joint (18 cases) were done by the use of ultrasound. Examinations by ultrasound were done with a Shimazu SDU-500 apparatus at 5.0 or 7.5 MHz, based on a linear electronic scanning method. Sagittal sections of the tissue were imaged on the screen and the needle was inserted into the joint Arthroscopy,
Vol. 7. No. 4, 1991
capsule. The image of the needle was readily seen by ultrasound. The joint was filled with saline, and then the trocar of the arthroscope was introduced into the joint with monitoring of the image of the trocar on the screen. When the synovial tissue of the hip joint was examined, the scope was inserted in the neck of the femur by an anterior approach. The joint surface was examined by a lateral approach with the patient on a traction table. Tumors or tumorous conditions could be imaged without difficulty, and the scope was inserted into the space close to the tumor. In the shoulder joint, the space between the head and acetabulum could be opened by the injection of saline. The bulging of the joint capsule made the introduction of the scope easy. In the ankle joint, the joint space between the tibia and the talus could be seen by plantal flexion. Posterior parts of the knee joint such as the posterior cruciate ligament or posterior horn of the meniscus were examined safely by the use of ultrasound, blood vessels were observed on the screen and the rear space was opened enough for introduction of the scope by the injection of saline. We succeeded in introducing the scope into 22 of the 24 joints with this method. Causes of failure were stiffness of the joint and insufficient capsule swelling. Our method can be called an objectoriented approach, for the scope is inserted close to the tissue to be examined. This is a relatively safe procedure because the blood vessels were imaged and there was no exposure to radiation. Trial of Arthroscopic Evaluation of Osteoarthritis of the Knee by Image Processing. Hirotaka Zguchi, Nobuo Matsui, Yoichi Taneda, Takashi Zto, and Sumikazu Tsuboguchi. Nagaya, Japan.
Arthroscopic images often cannot be used because of their bad focus or bad illumination. Another problem is turbidity of the irrigating fluid caused by bleeding, etc. Also, there is no way to make quantitative measurements in the arthroscopic evaluation of cartilage degeneration in osteoarthritis. To solve these problems, we developed a way to clarify such images and to establish a scale for the evaluation of degeneration by the use of image processing. Methods Five arthroscopic photographs (Fig. 2) were digitized with a photo-encoder (Photovics, Tamron