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Rehabilitation and successful arthroscopic surgery
182
The Knee 1994; 1: No 3
particularly on the lateral side. Associated degenerative features include a mal-alignment and flexion contracture. At diagnosis the above clinical features are present. There may be a response to physiotherapy with substantial improvement on mobility and strengthening exercise. The Fairbank’s sign becomes positive and subsequent early degenerative radiological features are present. An abnormal signal in the posterior segment of the meniscus on MRI is common in the middle-aged and elderly. Degenerative splits within the substance of the posterior segment may be seen without the changes interrupting the surface of the meniscal structure. These degenerative changes may then disturb the surface with a cleavage-type lesion. The shattered posterior segment is easily detected on MRI. There are various modes of treatment. Physiotherapy consisting of mobility and strengthening exercises, together with increasing activity, may be enough to satisfactorily settle the symptoms from an early degenerative meniscal lesion. Weight loss is important in the middle-aged and elderly obese patient. Arthroscopic partial meniscectomy and rarely a total meniscectomy can be performed as can meniscectomy and compartment debridement. It should be noted that there is IZO indication for meniscal suture in such degenerative meniscal tears. The posterior segment may require removal, using an arthroscopic ‘banana’ knife to start the dissection. This continues with the arthroscopic punch scissors and the posterior segment is then removed with appropriate rongeurs. The degenerative segment may require removal piecemeal, using a selection of punches, duck-billed punches, posterior-segment punches and rongeurs. The powered meniscotome is then used to remove irregular fragments and rim trimming. To study meniscectomy in arthroscopic debridement of the knee affected by early osteoarthritis we reviewed over an 11 year period - 1977 to 1988 - 276 knees with degenerative changes in 254 patients. These were treated by arthroscopic debridement and the most important part of this operative procedure was the treatment of the meniscal lesion. Of the 276 total, 224 were affected by meniscal tears: 190 were medial and 45 were lateral, with the posterior one-third being the most commonly affected. The posterior flap or tag tear was the most common type. In our study, 142 knees (51%) were treated by a meniscal and chondral debridement, and this was associated with 68% excellent or good results. Those with less severe degenerative changes, and treated by meniscal debridement alone (104 knees) had 86% excellent or good results, and so in early degenerative changes, meniscal surgery is important and very worthwhile. In conclusion, degenerative meniscal tears are frequently found. The posterior segment medial meniscus lesion is most common. Horizontal cleavage ‘tears, posterior tag tears, shattered and shredded posterior segments are found in degenerative menisci. Degenerative meniscal tears occur particularly in middleaged sports-active patients. Degenerative meniscal lesions are present in early degenerative arthritis of the knee. Arthroscopic meniscectomy may be required and
in the degenerative added. Rehabilitation
joint further debridement
and successful arthroscopic
may be
surgery
Tracy Maunder The aims of rehabilitation are to restore motion, strength and a pain-free joint as rapidly as possible. Each rehabilitation programme is tailored to the physical and psychological needs of the individual patient. The patient must be encouraged and motivated to ensure maximal participation. The close involvement of the surgeon links the rehabilitation to the objectives of surgery. Progress benchmarks for partial meniscectomy without associated pathology are, at 7-10 days, no pain or effusion, and at 2-4 weeks, a return to activities; and for degenerative meniscal tears are, at 24 weeks, no pain or effusion, and at 6-8 weeks, a return to activities. Stages of rehabilitation consist of pre-operative and immediate post-operative treatment, and long-term rehabilitation. Pre-operative treatment ideally consists of physically preparing the knee for surgery using exercises and electrotherapy as appropriate, and to explain the process so the patient understands and is mentally prepared. Immediate post-operative treatment consists of reducing effusion by using cryotherapy and electrotherapy, increasing joint motion, strength and flexibility of musculature by initiating an exercise programme to include stretching, static quadriceps work, flexion exercises and gait re-education. Long-term rehabilitation should incorporate closed kinetic chain exercises as soon as pain and effusion allows. During this type of exercise, the foot is fixed while the hip, knee and ankle move simultaneously over that fixed point. Closed kinetic chain exercises result in: improved functional stability and proprioception thereby helping to regain normal neuromuscular control of the knee; achieving larger strength gains by using a combination of isometric, concentric and eccentric muscular contraction rather than any one alone during each repetition of the exercise. Improved specificity of training by using exercises that approximate the desired activity. Examples are: cycling, stair machine, stepping exercises, squats, lungs, hydrotherapy, balancing on a wobble board, sports cord exercises, and treadmill walking and running. For contact sports and where explosive strength is necessary, the patient must be taught agility skills and plyometric exercises such as cutting manoeuvres, figureof-eight running, jumping, hopping and landing. Patient’s progress can be monitored accurately by isokinetic muscle-testing machines (e.g. Cybex). These computer-based systems generate graphical and numerical data on the strength, power and endurance of individual muscles. This information highlights areas of residual weakness and whether a patient is strong enough to return to his chosen sport. The isokinetic machines can also be used as part of the rehabilitation treatment and are useful motivational tools as goals can be quantified. In conclusion successful rehabilitation has three key ingredients: psychological preparation and motivation
Recent
of the patient, communication surgeon.
a tailored between
exercise programme, the physiotherapist
and and
IN THIS JOURNW
MAKE
This journal product,
is highly
IT WORK
service or event to a well defined
??
Long ‘shelf life’- advertising ??
companies
to advertise
and attentive
audience
their within a
editorial environment.
Butterworth-Heinemann
??
FOR YOU
specific and enables
perfectly-tailored
183
Surgeons performing arthroscopic meniscal repair are especially vulnerable to needlesticks. When palpating for a needle posteromedially, or posterolaterally, never advance the needle further through the meniscus. Double gloving should be done at all times. Outer gloves should be discarded when applying the final dressings. Gloves should not be totally removed until all contaminated clothing has been removed, including soiled shoe covers. If contamination of exposed skin occurs, the contaminated area should be immediately washed with soap and water. If a skin puncture or cut occurs, the wound should be washed with soap and water or 70% isopropyl alcohol. A test for HIV should be done and repeated at 3, 6 and 12 months after injury. The use of allografts poses a risk to the recipient. The surgeon should be aware of the guidelines used by the tissue banks for specimen collection and HIV testing. There has been a seroconversion in a patient after a fresh frozen allograft was used during ACL reconstruction. Sterilization of the graft by irradiation may structurally weaken it, and over 4 MRads of irradiation may be required for eradication of HIV virus. Aerosolization may also occur during surgery, secondary to power saws and electrocautery. Although in the laboratory setting, viable HIV virions have been cultured from aerosolized blood, it is unknown to what extent this poses a risk to the operating surgeon. Space suits should be worn during surgery on known HIVpositive patients when aerosolization may occur. Sterilization of arthroscopic equipment must be done carefully. Disinfection, used extensively in the dental field, is inadequate and should be condemned. Sterilization with 2% glutaraldehyde requires a minimum of 10 immersion at 25°C. Slowly developing damage to arthroscopes still occurs. It may be better to sterilely bag the TV camera rather than attempting to sterilize it.
AIDS and arthroscopic surgery Dilworth Cannon Worldwide it is estimated that there are over 10 000 000 cases of HIV infection. The Centre for Diseases Control (CDC) estimates that by the year 2000, this number may rise to 40 000 000. They estimate that the number of HIV carriers in the United States is 1 000 000 to 1 500 000. Because it is against the law to test a patient for HIV against his or her will, this figure may be underestimated. The CDC has said that over 80% of HIV-infected persons in the United States do not know that they are infected. Hence this presents an immense problem to the arthroscopic surgeon, unless he or she engages in extensive HIV testing of patients. The HIV virus has an RNA genome and, upon entrance into a cell, may remain dormant, or may modulate into viral replication. Viral titres are highest during the initial phase of HIV infection and during the terminal phase of AIDS, and lo3 to lo4 particles per ml is common. In asymptomatic HIV-infected persons, the titre may be 10’ to lo2 per ml. It may take 6 to 8 weeks after infection for antibody formation to occur. The mean time between HIV infection and manifestation of symptoms of AIDS is approximately 10 years. Because the HIV status of most patients will be unknown it is best to presume that all patients are infected. This forms the basis of universal precautions. Surgical garb and draping materials currently available are inadequate. Wearing impervious gowns or inner gowns and boots is mandatory. We are required to wear a face shield for splash protection. Pouches to collect fluid about the knee during arthroscopy should be used.
ADWRTISE
Advances in Meniscal Surgery
journals
provide:
Precision targeting
goes on working, High pass-on
reinforcing
readership
Full details of advertisement rates, mechanical data, and copy dates can be obtained MTB Advertising, 11 Harts Gardens, Guildford. Telephone: +44 (0) 483 578507 Fax: +44
UTTERWORTH EINEMANN
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information on circulation from: Surrey GU2 6QA UK (0) 483 572678
The Knee 1994; 1: No 3
particularly on the lateral side. Associated degenerative features include a mal-alignment and flexion contracture. At diagnosis the above clinical features are present. There may be a response to physiotherapy with substantial improvement on mobility and strengthening exercise. The Fairbank’s sign becomes positive and subsequent early degenerative radiological features are present. An abnormal signal in the posterior segment of the meniscus on MRI is common in the middle-aged and elderly. Degenerative splits within the substance of the posterior segment may be seen without the changes interrupting the surface of the meniscal structure. These degenerative changes may then disturb the surface with a cleavage-type lesion. The shattered posterior segment is easily detected on MRI. There are various modes of treatment. Physiotherapy consisting of mobility and strengthening exercises, together with increasing activity, may be enough to satisfactorily settle the symptoms from an early degenerative meniscal lesion. Weight loss is important in the middle-aged and elderly obese patient. Arthroscopic partial meniscectomy and rarely a total meniscectomy can be performed as can meniscectomy and compartment debridement. It should be noted that there is IZO indication for meniscal suture in such degenerative meniscal tears. The posterior segment may require removal, using an arthroscopic ‘banana’ knife to start the dissection. This continues with the arthroscopic punch scissors and the posterior segment is then removed with appropriate rongeurs. The degenerative segment may require removal piecemeal, using a selection of punches, duck-billed punches, posterior-segment punches and rongeurs. The powered meniscotome is then used to remove irregular fragments and rim trimming. To study meniscectomy in arthroscopic debridement of the knee affected by early osteoarthritis we reviewed over an 11 year period - 1977 to 1988 - 276 knees with degenerative changes in 254 patients. These were treated by arthroscopic debridement and the most important part of this operative procedure was the treatment of the meniscal lesion. Of the 276 total, 224 were affected by meniscal tears: 190 were medial and 45 were lateral, with the posterior one-third being the most commonly affected. The posterior flap or tag tear was the most common type. In our study, 142 knees (51%) were treated by a meniscal and chondral debridement, and this was associated with 68% excellent or good results. Those with less severe degenerative changes, and treated by meniscal debridement alone (104 knees) had 86% excellent or good results, and so in early degenerative changes, meniscal surgery is important and very worthwhile. In conclusion, degenerative meniscal tears are frequently found. The posterior segment medial meniscus lesion is most common. Horizontal cleavage ‘tears, posterior tag tears, shattered and shredded posterior segments are found in degenerative menisci. Degenerative meniscal tears occur particularly in middleaged sports-active patients. Degenerative meniscal lesions are present in early degenerative arthritis of the knee. Arthroscopic meniscectomy may be required and
in the degenerative added. Rehabilitation
joint further debridement
and successful arthroscopic
may be
surgery
Tracy Maunder The aims of rehabilitation are to restore motion, strength and a pain-free joint as rapidly as possible. Each rehabilitation programme is tailored to the physical and psychological needs of the individual patient. The patient must be encouraged and motivated to ensure maximal participation. The close involvement of the surgeon links the rehabilitation to the objectives of surgery. Progress benchmarks for partial meniscectomy without associated pathology are, at 7-10 days, no pain or effusion, and at 2-4 weeks, a return to activities; and for degenerative meniscal tears are, at 24 weeks, no pain or effusion, and at 6-8 weeks, a return to activities. Stages of rehabilitation consist of pre-operative and immediate post-operative treatment, and long-term rehabilitation. Pre-operative treatment ideally consists of physically preparing the knee for surgery using exercises and electrotherapy as appropriate, and to explain the process so the patient understands and is mentally prepared. Immediate post-operative treatment consists of reducing effusion by using cryotherapy and electrotherapy, increasing joint motion, strength and flexibility of musculature by initiating an exercise programme to include stretching, static quadriceps work, flexion exercises and gait re-education. Long-term rehabilitation should incorporate closed kinetic chain exercises as soon as pain and effusion allows. During this type of exercise, the foot is fixed while the hip, knee and ankle move simultaneously over that fixed point. Closed kinetic chain exercises result in: improved functional stability and proprioception thereby helping to regain normal neuromuscular control of the knee; achieving larger strength gains by using a combination of isometric, concentric and eccentric muscular contraction rather than any one alone during each repetition of the exercise. Improved specificity of training by using exercises that approximate the desired activity. Examples are: cycling, stair machine, stepping exercises, squats, lungs, hydrotherapy, balancing on a wobble board, sports cord exercises, and treadmill walking and running. For contact sports and where explosive strength is necessary, the patient must be taught agility skills and plyometric exercises such as cutting manoeuvres, figureof-eight running, jumping, hopping and landing. Patient’s progress can be monitored accurately by isokinetic muscle-testing machines (e.g. Cybex). These computer-based systems generate graphical and numerical data on the strength, power and endurance of individual muscles. This information highlights areas of residual weakness and whether a patient is strong enough to return to his chosen sport. The isokinetic machines can also be used as part of the rehabilitation treatment and are useful motivational tools as goals can be quantified. In conclusion successful rehabilitation has three key ingredients: psychological preparation and motivation
Recent
of the patient, communication surgeon.
a tailored between
exercise programme, the physiotherapist
and and
IN THIS JOURNW
MAKE
This journal product,
is highly
IT WORK
service or event to a well defined
??
Long ‘shelf life’- advertising ??
companies
to advertise
and attentive
audience
their within a
editorial environment.
Butterworth-Heinemann
??
FOR YOU
specific and enables
perfectly-tailored
183
Surgeons performing arthroscopic meniscal repair are especially vulnerable to needlesticks. When palpating for a needle posteromedially, or posterolaterally, never advance the needle further through the meniscus. Double gloving should be done at all times. Outer gloves should be discarded when applying the final dressings. Gloves should not be totally removed until all contaminated clothing has been removed, including soiled shoe covers. If contamination of exposed skin occurs, the contaminated area should be immediately washed with soap and water. If a skin puncture or cut occurs, the wound should be washed with soap and water or 70% isopropyl alcohol. A test for HIV should be done and repeated at 3, 6 and 12 months after injury. The use of allografts poses a risk to the recipient. The surgeon should be aware of the guidelines used by the tissue banks for specimen collection and HIV testing. There has been a seroconversion in a patient after a fresh frozen allograft was used during ACL reconstruction. Sterilization of the graft by irradiation may structurally weaken it, and over 4 MRads of irradiation may be required for eradication of HIV virus. Aerosolization may also occur during surgery, secondary to power saws and electrocautery. Although in the laboratory setting, viable HIV virions have been cultured from aerosolized blood, it is unknown to what extent this poses a risk to the operating surgeon. Space suits should be worn during surgery on known HIVpositive patients when aerosolization may occur. Sterilization of arthroscopic equipment must be done carefully. Disinfection, used extensively in the dental field, is inadequate and should be condemned. Sterilization with 2% glutaraldehyde requires a minimum of 10 immersion at 25°C. Slowly developing damage to arthroscopes still occurs. It may be better to sterilely bag the TV camera rather than attempting to sterilize it.
AIDS and arthroscopic surgery Dilworth Cannon Worldwide it is estimated that there are over 10 000 000 cases of HIV infection. The Centre for Diseases Control (CDC) estimates that by the year 2000, this number may rise to 40 000 000. They estimate that the number of HIV carriers in the United States is 1 000 000 to 1 500 000. Because it is against the law to test a patient for HIV against his or her will, this figure may be underestimated. The CDC has said that over 80% of HIV-infected persons in the United States do not know that they are infected. Hence this presents an immense problem to the arthroscopic surgeon, unless he or she engages in extensive HIV testing of patients. The HIV virus has an RNA genome and, upon entrance into a cell, may remain dormant, or may modulate into viral replication. Viral titres are highest during the initial phase of HIV infection and during the terminal phase of AIDS, and lo3 to lo4 particles per ml is common. In asymptomatic HIV-infected persons, the titre may be 10’ to lo2 per ml. It may take 6 to 8 weeks after infection for antibody formation to occur. The mean time between HIV infection and manifestation of symptoms of AIDS is approximately 10 years. Because the HIV status of most patients will be unknown it is best to presume that all patients are infected. This forms the basis of universal precautions. Surgical garb and draping materials currently available are inadequate. Wearing impervious gowns or inner gowns and boots is mandatory. We are required to wear a face shield for splash protection. Pouches to collect fluid about the knee during arthroscopy should be used.
ADWRTISE
Advances in Meniscal Surgery
journals
provide:
Precision targeting
goes on working, High pass-on
reinforcing
readership
Full details of advertisement rates, mechanical data, and copy dates can be obtained MTB Advertising, 11 Harts Gardens, Guildford. Telephone: +44 (0) 483 578507 Fax: +44
UTTERWORTH EINEMANN
your sales message
information on circulation from: Surrey GU2 6QA UK (0) 483 572678