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Osteochondritis dissecans of the lateral femoral condyle—Natural history and treatment
322
ABSTRACTS
In all cases, SEPs were recorded at the cerebral cortex on electric stimulation of the ACL. The greatest potentials were recorded on stimulation of the midsubstance of the ligament and the least at the femoral end. These findings provide direct evidence for, and strongly support the presence of, active proprioceptive receptors within the intact ACL of the human knee. Correlation of Patello-Femoral Crepitus with Arthroscopic Findings. Stephen R. Soffer, Martin Yahiro, Bruce Wolock, Leslie Matthews, and O’Donnell. Baltimore, Maryland, U.S.A.
John
Crepitation of the patellofemoral joint is thought to be a characteristic physical finding of chondromalacia patellae (CMP). There is controversy as to whether patellofemoral crepitus (PFC) is specific for patellofemoral joint pathology. The purpose of this study is to examine the relationship of the physical finding of crepitus to the arthroscopic findings in the patellofemoral joint. This is a prospective blind study of 100 knees in 99 patients undergoing arthroscopic surgery. There are 67 men and 32 women, ages 11-85 years (mean age = 34.6 years). Preoperatively, crepitus was graded by severity (grades O-3) in three ranges of knee flexion, under loaded and unloaded conditions. Routine arthroscopies with care to examine and probe the articular surface of the patella were performed. Knee diagrams were then completed documenting size, location, and grade of CMP. In all three arcs of knee flexion, under loaded and unloaded conditions, low grades of PFC predicted low grades of CMP and high grades of PFC predicted high grades of CMP (p < 0.01). There was no correlation between the grade of PFC and the location of size of the CMP. There was no relationship between PFC and the presence of other intraarticular pathology. PFC is an accurate predictor of patellofemoral joint pathology and is a useful diagnostic aid in delineating anterior knee pain. Measurement of PFC in three arcs of knee flexion under loaded and unloaded conditions is not clinically useful. Technique and Results of Arthroscopic Treatment of Calcific Tendonitis of the Rotator Cuff Using Fluoroscopic Localization. Stephen C. Weber. Sacramento, California, U.S.A. Arthroscopy.
Vol. 7, No. 3, 1991
Arthroscopic removal of calcific deposits has been the subject of several small studies. Early studies have shown the technique to be efficacious but difticult, because the calcitic deposits are buried within the substance of the rotator cuff, and previously described techniques have required blind probing of the rotator cuff to localize the calcitic deposits. This causes iatrogenic damage to the rotator cuff, and significantly extends the time required to perform this surgery. Intraoperative fluoroscopic localization of calcium has not been previously described. In this study, 20 patients with a mean age of 43.7 years who failed at least 6 months of conservative management with calcific tendonitis were treated. Sixteen were female and four were male. Diagnostic arthroscopy of the joint was performed, and then bursoscopy. A Phillips BV25 image intensifier was then brought over the lateral aspect of the shoulder and was used to create an anteroposterior image of the shoulder. This was used to place a 4.5-mm synovial resector tip directly over the deposit; the deposit was then removed. Calcium fragments were arthroscopically visualized in all patients using this technique; fluoroscopic time averaged 2.2 min. Arthroscopic acromioplasty was performed in all cases. Mean follow-up averaged 17 months (SD = 5.92). Sixteen patients had complete relief of pain, two had some relief, and two were not improved. No complications were encountered. The addition of fluoroscopic control to the arthroscopic removal of calcium appears to significantly improve the predictability of this procedure for the rare patient who fails conservative management for this condition. Osteochondritis Dissecans of the Lateral Femoral CondyI+Natural History and Treatment. John C. Garrett. Atlanta, Georgia, U.S.A. In osteochondritis dissecans, lesions of the lateral femoral condyles are less common than those of the medial condyle and have unique characteristics that affect their natural history and treatment. Formerly, they have been relatively neglected in treatises on osteochondral dissecans. To gain a greater appreciation of their attributes, 28 consecutive cases of osteochondritis dissecans of the lateral femoral condyle treated from 1984 through 1990 were studied and compared with a similar number of lesions of the medial femoral condyle. Patients were studied prospectively as to clinical presentation including Lysholm scores, roentgenographic
ABSTRACTS
and arthroscopic findings, and response to treatment. On the ‘average, lesions of the lateral condyle were larger than those of the medial condyle (11.5 versus 6.1 cm*). “Gigantic” lesions were more common as well. Lesions tended to spread across the entire width of the condyle and occurred further posterior on the weight-bearing surface affecting the tibiofemoral articulation principally during “roll back” rather than the tibiofemoral articulation in extension. Apparent widening of the joint space noted principally on tunnel roentgenographs was found to be caused by deformity with flattening of the normal curvature of the condyle. Lateral lesions often had multiple areas of calcification (average number of “islands” 3.4 versus 1.4 of the medial condyle). Often only a slim underpinning of bone was present and at times little if any was noted. This was correlated with a greater tendency to fragmentation, with small segments often disengaging one at a time, making replacement impractical. Craters resulting from the lateral femoral condylar lesions were large and invariably symptomatic. Many patients experienced a “clunk” each time the knee was flexed. Degenerative changes occurred readily. Replacement of loose fragments was undertaken when practical. When replacement was impossible, and abrasion arthroplasty proved unsuccessful in treating the large lateral condylar craters. Patching with fresh osteochondral allografts was offered as a more reasonable solution and was performed in 13 cases. Interscalene Block for Shoulder Arthroscopy: Comparison with General Anesthesia. Louis 17. Bigliani, Evan L. Flatow, Richard Weiss, Robin Brown, and Carolyn P. Greenberg. New York, New York, and
Van Nuys, California,
U.S.A.
Interscalene brachial plexus block is reported to be safe and effective for major reconstructive shoulder surgery. However, it is not commonly employed for shoulder arthroscopy. The purpose of this study is to compare interscalene block to general anesthesia in a group of patients undergoing shoulder arthroscopy. One hundred three patients who underwent shoulder arthroscopy were evaluated. Group I consisted of 40 patients undergoing general anesthesia and group II consisted of 63 patients undergoing interscalene block. Diagnoses and surgical treatment were similar in the two groups. In group I, the average age was 37 years (range
18-61). There were 25 men and 15 women. There were no surgical complications. In the immediate postoperative period, 18 patients (45%) required i.m. or i.v. pain medication. Seventeen patients (43%) experienced nausea and vomiting requiring medication and 10 patients (25%) were unable to void. Nineteen patients (48%) required overnight hospital admission, and three of these patients (8%) required observation until the 2nd postoperative day. Reasons for admission were shoulder pain requiring i.m. or i.v. pain medication (18 patients), nausea and vomiting (14 patients), inability to void (10 patients), oversedation (5 patients), elevated temperature (3 patients), labile blood pressure (2 patients), diabetes mellitus (1 patient), and pseudocholinesterase deficiency (I patient). Nine of 19 overnight admissions (47%) were cases started in the late afternoon. In group II, the average age was 45 years (range 19-69). There were 37 men and 26 women. Ten blocks (16%) were abandoned for the following reasons: inadequate anesthesia (six patients), difficulty breathing (one patient), anxiety (two), and difficulty swallowing (one). Other side effects of the block were hoarseness in four patients (6%), Homer’s syndrome in three patients (5%), and anxiety in two patients (3%). In the immediate postoperative period, nine patients (14%) had pain requiring i.m. or i.v. pain medications, and live patients (8%) had nausea and vomiting. Fifty-two patients (83%) were discharged home on the day of surgery. Eleven patients (17%) required overnight admission; four of them were failed blocks and six were late afternoon cases. This report represents our initial experience with interscalene block and includes a significant leaming curve. Technical factors associated with block failure include inadequate volume of agent, improper placement, inadequate explanation of side effects to the patient resulting in anxiety, and insufticient sedation. With increasing experience, adequate explanation of side effects, and appropriate sedation, the incidence of failed blocks has recently been significantly reduced. In summary, interscalene brachial plexus block is a safe and effective means of anesthesia for shoulder arthroscopy. Compared with general anesthesia, it results in significantly fewer postanesthetic complications and is ideal for outpatient surgery. Ligament Strain and Ankle Joint Opening During Invasive Ankle Distraction. Jeffrey Albert, Paul R. Arthroscopy,
Vol. 7, No. 3, 1991
ABSTRACTS
In all cases, SEPs were recorded at the cerebral cortex on electric stimulation of the ACL. The greatest potentials were recorded on stimulation of the midsubstance of the ligament and the least at the femoral end. These findings provide direct evidence for, and strongly support the presence of, active proprioceptive receptors within the intact ACL of the human knee. Correlation of Patello-Femoral Crepitus with Arthroscopic Findings. Stephen R. Soffer, Martin Yahiro, Bruce Wolock, Leslie Matthews, and O’Donnell. Baltimore, Maryland, U.S.A.
John
Crepitation of the patellofemoral joint is thought to be a characteristic physical finding of chondromalacia patellae (CMP). There is controversy as to whether patellofemoral crepitus (PFC) is specific for patellofemoral joint pathology. The purpose of this study is to examine the relationship of the physical finding of crepitus to the arthroscopic findings in the patellofemoral joint. This is a prospective blind study of 100 knees in 99 patients undergoing arthroscopic surgery. There are 67 men and 32 women, ages 11-85 years (mean age = 34.6 years). Preoperatively, crepitus was graded by severity (grades O-3) in three ranges of knee flexion, under loaded and unloaded conditions. Routine arthroscopies with care to examine and probe the articular surface of the patella were performed. Knee diagrams were then completed documenting size, location, and grade of CMP. In all three arcs of knee flexion, under loaded and unloaded conditions, low grades of PFC predicted low grades of CMP and high grades of PFC predicted high grades of CMP (p < 0.01). There was no correlation between the grade of PFC and the location of size of the CMP. There was no relationship between PFC and the presence of other intraarticular pathology. PFC is an accurate predictor of patellofemoral joint pathology and is a useful diagnostic aid in delineating anterior knee pain. Measurement of PFC in three arcs of knee flexion under loaded and unloaded conditions is not clinically useful. Technique and Results of Arthroscopic Treatment of Calcific Tendonitis of the Rotator Cuff Using Fluoroscopic Localization. Stephen C. Weber. Sacramento, California, U.S.A. Arthroscopy.
Vol. 7, No. 3, 1991
Arthroscopic removal of calcific deposits has been the subject of several small studies. Early studies have shown the technique to be efficacious but difticult, because the calcitic deposits are buried within the substance of the rotator cuff, and previously described techniques have required blind probing of the rotator cuff to localize the calcitic deposits. This causes iatrogenic damage to the rotator cuff, and significantly extends the time required to perform this surgery. Intraoperative fluoroscopic localization of calcium has not been previously described. In this study, 20 patients with a mean age of 43.7 years who failed at least 6 months of conservative management with calcific tendonitis were treated. Sixteen were female and four were male. Diagnostic arthroscopy of the joint was performed, and then bursoscopy. A Phillips BV25 image intensifier was then brought over the lateral aspect of the shoulder and was used to create an anteroposterior image of the shoulder. This was used to place a 4.5-mm synovial resector tip directly over the deposit; the deposit was then removed. Calcium fragments were arthroscopically visualized in all patients using this technique; fluoroscopic time averaged 2.2 min. Arthroscopic acromioplasty was performed in all cases. Mean follow-up averaged 17 months (SD = 5.92). Sixteen patients had complete relief of pain, two had some relief, and two were not improved. No complications were encountered. The addition of fluoroscopic control to the arthroscopic removal of calcium appears to significantly improve the predictability of this procedure for the rare patient who fails conservative management for this condition. Osteochondritis Dissecans of the Lateral Femoral CondyI+Natural History and Treatment. John C. Garrett. Atlanta, Georgia, U.S.A. In osteochondritis dissecans, lesions of the lateral femoral condyles are less common than those of the medial condyle and have unique characteristics that affect their natural history and treatment. Formerly, they have been relatively neglected in treatises on osteochondral dissecans. To gain a greater appreciation of their attributes, 28 consecutive cases of osteochondritis dissecans of the lateral femoral condyle treated from 1984 through 1990 were studied and compared with a similar number of lesions of the medial femoral condyle. Patients were studied prospectively as to clinical presentation including Lysholm scores, roentgenographic
ABSTRACTS
and arthroscopic findings, and response to treatment. On the ‘average, lesions of the lateral condyle were larger than those of the medial condyle (11.5 versus 6.1 cm*). “Gigantic” lesions were more common as well. Lesions tended to spread across the entire width of the condyle and occurred further posterior on the weight-bearing surface affecting the tibiofemoral articulation principally during “roll back” rather than the tibiofemoral articulation in extension. Apparent widening of the joint space noted principally on tunnel roentgenographs was found to be caused by deformity with flattening of the normal curvature of the condyle. Lateral lesions often had multiple areas of calcification (average number of “islands” 3.4 versus 1.4 of the medial condyle). Often only a slim underpinning of bone was present and at times little if any was noted. This was correlated with a greater tendency to fragmentation, with small segments often disengaging one at a time, making replacement impractical. Craters resulting from the lateral femoral condylar lesions were large and invariably symptomatic. Many patients experienced a “clunk” each time the knee was flexed. Degenerative changes occurred readily. Replacement of loose fragments was undertaken when practical. When replacement was impossible, and abrasion arthroplasty proved unsuccessful in treating the large lateral condylar craters. Patching with fresh osteochondral allografts was offered as a more reasonable solution and was performed in 13 cases. Interscalene Block for Shoulder Arthroscopy: Comparison with General Anesthesia. Louis 17. Bigliani, Evan L. Flatow, Richard Weiss, Robin Brown, and Carolyn P. Greenberg. New York, New York, and
Van Nuys, California,
U.S.A.
Interscalene brachial plexus block is reported to be safe and effective for major reconstructive shoulder surgery. However, it is not commonly employed for shoulder arthroscopy. The purpose of this study is to compare interscalene block to general anesthesia in a group of patients undergoing shoulder arthroscopy. One hundred three patients who underwent shoulder arthroscopy were evaluated. Group I consisted of 40 patients undergoing general anesthesia and group II consisted of 63 patients undergoing interscalene block. Diagnoses and surgical treatment were similar in the two groups. In group I, the average age was 37 years (range
18-61). There were 25 men and 15 women. There were no surgical complications. In the immediate postoperative period, 18 patients (45%) required i.m. or i.v. pain medication. Seventeen patients (43%) experienced nausea and vomiting requiring medication and 10 patients (25%) were unable to void. Nineteen patients (48%) required overnight hospital admission, and three of these patients (8%) required observation until the 2nd postoperative day. Reasons for admission were shoulder pain requiring i.m. or i.v. pain medication (18 patients), nausea and vomiting (14 patients), inability to void (10 patients), oversedation (5 patients), elevated temperature (3 patients), labile blood pressure (2 patients), diabetes mellitus (1 patient), and pseudocholinesterase deficiency (I patient). Nine of 19 overnight admissions (47%) were cases started in the late afternoon. In group II, the average age was 45 years (range 19-69). There were 37 men and 26 women. Ten blocks (16%) were abandoned for the following reasons: inadequate anesthesia (six patients), difficulty breathing (one patient), anxiety (two), and difficulty swallowing (one). Other side effects of the block were hoarseness in four patients (6%), Homer’s syndrome in three patients (5%), and anxiety in two patients (3%). In the immediate postoperative period, nine patients (14%) had pain requiring i.m. or i.v. pain medications, and live patients (8%) had nausea and vomiting. Fifty-two patients (83%) were discharged home on the day of surgery. Eleven patients (17%) required overnight admission; four of them were failed blocks and six were late afternoon cases. This report represents our initial experience with interscalene block and includes a significant leaming curve. Technical factors associated with block failure include inadequate volume of agent, improper placement, inadequate explanation of side effects to the patient resulting in anxiety, and insufticient sedation. With increasing experience, adequate explanation of side effects, and appropriate sedation, the incidence of failed blocks has recently been significantly reduced. In summary, interscalene brachial plexus block is a safe and effective means of anesthesia for shoulder arthroscopy. Compared with general anesthesia, it results in significantly fewer postanesthetic complications and is ideal for outpatient surgery. Ligament Strain and Ankle Joint Opening During Invasive Ankle Distraction. Jeffrey Albert, Paul R. Arthroscopy,
Vol. 7, No. 3, 1991