Osteonecrosis after contact neodymium:yttrium aluminum garnet arthroscopic laser meniscectomy

OBJECTIVE: The purpose of this report is to describe two cases of osteonecrosis that occurred after arthroscopic meniscectomy with a contact neodymium:yttrium aluminum garnet laser system. The patients developed increasing knee pain and disability 5 months and 6 months after laser meniscectomy. MR imaging showed subchondral osteonecrosis in the femoral condyle and tibial plateau immediately adjacent to the site of laser meniscectomy in both patients. One patient required a total knee replacement to alleviate knee symptoms, and the other patient required a tibial osteotomy and surgical elevation of collapsed tibial articular surface. CONCLUSION: To our knowledge, this complication of laser arthroscopic meniscectomy has not been reported in the radiology literature. The clinical and MR imaging features of this important complication are described and possible causative mechanisms are discussed.     

Arthroscopy: possibilities and limitations in the diagnosis and therapy of meniscus lesions

The menisci consist of fibrocartilage and are an important supporting structure of the knee joint. They are poorly vascularized and have to withstand a high mechanical strain and load; therefore, lesions are common, especially on the medial side. Meniscal lesions are among the most frequent surgical procedures in orthopedic surgery. Meniscal lesions are diagnosed by a careful clinical examination in 80% of all cases in spite of modern imaging techniques such as magnetic resonance imaging (MRI). In the last 15 years, arthroscopic meniscectomy has become the 'golden standard' of therapy. Arthroscopy provides a powerful tool to precisely locate and classify the type of meniscus injury and to perform arthroscopic meniscectomy at the same time. This means less morbidity, reduced hospitalization time and earlier return to work and hence reduced costs. The endoscopic technique allows to exactly remove the damaged parts of the meniscus with precision instruments (partial meniscectomy). Former open techniques only allowed the complete removal of the meniscus. The arthroscopic techniques used nowadays allow a preservation of the functionally important edge of the meniscus, which is responsible for the stability and the biomechanics of the knee joint and can thus prevent an early onset of arthrosis. In rare cases of peripheral meniscal tears in young patients, arthroscopic refixation is an advantageous treatment option. Partial arthroscopic meniscectomy and arthroscopic meniscus refixation are challenging therapeutic procedures that require a trained and experienced orthopedic surgeon. Today diagnostic arthroscopy is more and more abandoned in favour of noninvasive and reliable MRI techniques. MRI is also useful in cases of previous knee surgery and clinically unclear findings, but should not be used on a routine basis. In differential diagnosis, the orthopedic surgeon always has to evaluate the MRI findings as to their impact. Today, arthroscopic knee surgery is a reliable, technically sophisticated and standardized technique to treat meniscal damages of all patients. There is a relatively low rate of complications, provided that the indication for the procedure is critically applied and restricted to patients with sufficient clinical and MRI findings.     

Long-term results after arthroscopic meniscectomy. The role of preexisting cartilage fibrillation in a 13 year follow-up of 60 patients

Sixty patients with stable knees and arthroscopic menisectomy were matched into two groups according to the presence of early degenerative changes at the operation. Patients with severe cartilage changes were excluded. The patients were between 20 and 40 years of age at the operation and no patient had previous surgery on the involved knee. The intraarticular findings were documented at surgery and the patients were re-examined 12 to 15 years after the meniscectomy. Pre-existing cartilage fibrillation at the meniscectomy did not seem to influence the long-term results. At the follow-up no difference was found between the groups at the physical examination, in subjective complaints, in knee function and activity or in radiographic findings. In the total group 62% had early signs of arthrosis (Fairbank changes) and 42% narrowing of the joint space (Ahlb?ck grade 1-2) in the operated knee. No one had more severe changes. Radiographic signs of arthrosis were 4 times commoner in the operated knee compared to the non-operated knee after partial meniscectomy and 7 times commoner in the operated knee after subtotal meniscectomy. Arthrosis at the follow-up was seen three times more often in patients older than 30 years of age at surgery than in younger patients. The functional outcome was good and 70% were still active in sports compared to 90% before the operation.     

Delayed hypersensitivity reaction of the knee after injection of arthroscopy portals with bupivacaine (marcaine)

The number of arthroscopic procedures performed annually for the management of intraarticular injuries has grown at an exponential rate. Whether done with the patient under general anesthesia or local anesthesia supplemented with intravenous sedation, it is common practice to postoperatively inject each portal as well as the joint with a local anesthetic to provide pain relief in the transition to the recovery room and discharge after outpatient surgery. To our knowledge, no previous reports of localized urticaria and delayed hypersensitivity reaction have been reported in the postarthroscopy setting. We are reporting a case of delayed hypersensitivity reaction and urticaria of the knee that presented after bupivacaine (Marcaine) injection of arthroscopic portals after routine meniscectomy.     

Meniscal lesions

The menisci of the knee play an important role in joint congruence, stability and absorption. They thus contribute to cartilage preservation. This is why current treatment of meniscal lesions is based on the notion of maximum preservation of the menisci: meniscectomy as partial as possible, but also whenever possible, meniscal repair (meniscal suture), or abstention from surgery (the lesion left in place). The type of therapy depends on the one hand on the type of meniscal lesion (traumatic or degenerative), but also on the context (age, state of the cartilage, and especially state of the ligaments). In case of associated rupture of the anterior cruciate ligament, treatment of the ligament lesion (ACL reconstruction) usually takes precedence over treatment of the meniscal lesion; the latter, whenever possible, is preserved (suture or abstention). In the case of meniscal lesion on an otherwise intact knee, the usual approach is very partial arthroscopic meniscectomy. Arthroscopy has shortened the immediate postsurgical effect, but long-term results still show a certain percentage of narrowing joint's space, in particular on the lateral meniscus.     

The holmium YAG laser in office based arthroscopy of the knee: comparison with standard interventional instruments in patients with arthritis

OBJECTIVE: To confirm the feasibility of laser assisted technology in an office based rheumatology practice and to compare selected outcome variables with those of conventional arthroscopic cutting tools. METHODS: A prospective analysis of 70 office based arthroscopies on 70 patients with knee arthritis over an 8 month period. All patients met specific criteria for office based arthroscopy. Thirty-six patients had interventions with conventional cutting tools and 34 patients had interventions with a 40 watt holmium YAG laser. Variables assessed included procedure time, length of recuperative period, and postprocedural pain. RESULTS: Laser assisted arthroscopy was performed in 34 cases without side effects or complications. Patients who received laser treatment had a shorter recuperative period, less postprocedural pain, and fewer hemarthroses than patients treated with conventional methods. CONCLUSION: While recognizing the shortcomings and possible complications associated with laser surgery, we conclude that laser use in an office setting is not only feasible but may in the future be an excellent method for office based arthroscopic treatment of the arthritic knee.     

The effect of allograft meniscal replacement on intraarticular contact area and pressures in the human knee. A biomechanical study

To define the biomechanical effects of total lateral meniscectomy and of subsequent lateral meniscal allograft replacement on load transmission and distribution across the human knee, we mounted 10 fresh-frozen young human cadaveric knees on a mechanical testing system. Peak pressure and contact area profiles were determined at 0 degrees, 30 degrees, and 60 degrees of knee flexion using pressure-sensitive film and a densitometer. Load transmission profiles were determined for each knee in a sequential test order: 1) intact knee, 2) after lateral meniscectomy, 3) after implantation of size-matched meniscal allograft fixed with bone plugs, and 4) after release of the anterior and posterior horn attachments of the allograft. Total lateral meniscectomy resulted in a 45% to 50% decrease in total contact area. Allograft replacement increased total contact area by 42% to 65% as compared with total meniscectomy at all flexion angles. After release of the anterior and posterior horn attachments, contact area was identical to that after total meniscectomy. Total lateral meniscectomy resulted in a 235% to 335% increase in peak local contact pressure. Allograft replacement decreased these pressures by 55% to 65% at all flexion angles, but they remained significantly greater than those in the intact state. After release of the anterior and posterior horn attachments, contact pressures were identical to those after total meniscectomy. Compared with total meniscectomy, meniscal allograft transplantation significantly increases contact area and decreases peak local contact pressures, but any biomechanical advantages are lost without bone plug fixation of the anterior and posterior horns.     

Rehabilitation following arthroscopic meniscectomy

Meniscal injuries are reported to be the most common injury sustained by athletes, with sports injuries being responsible for over 30% of the total number of lesions. Treatment of meniscal lesions has evolved considerably over the past 20 years and partial meniscectomies, or menisci repairs, are now the treatment of choice for the majority of lesions. Following arthroscopic meniscectomy, patients are routinely able to walk without support within 1 to 3 days, return to work after 1 to 2 weeks, resume athletic training by 2 to 4 weeks and return to competition in 3 to 4 weeks. Physiotherapy has been widely prescribed following arthroscopic meniscectomy and exercise protocols have been described in the literature. However, few studies have actually ascertained whether or not physiotherapy accelerates recovery. From these studies, there is little doubt that some form of rehabilitation, e.g. pain control or exercises, may be effective in accelerating the recovery of muscle strength to preoperative values. Therefore, whether or not physiotherapy is required following arthroscopic meniscectomy may depend on the presence or absence of preoperative strength deficits, and thus, on whether it is the dominant or nondominant leg that is injured. In patients with no preoperative deficits, and a normal post-surgery evolution, full recovery may be expected within 6 weeks if pain and swelling are brought under control. Physiotherapy intervention may not, perhaps, be justified for these patients, except in professional athletes where a faster return to preoperative values may be desired.     

Painful knees in older patients: radionuclide diagnosis of possible osteonecrosis with spontaneous resolution

The syndrome of osteonecrosis of the femur at the knee presents as sudden onset of knee pain in elderly patients. It is classically associated with a subchondral radiolucency and a positive radionuclide bone scan. The lesion may progress to collapse of the bone. In this report, twelve cases are described in which the clinical entity of osteonecrosis of the femoral condyle was diagnosed because the patients had a clinical picture identical to that of osteonecrosis and also had positive bone scans. However, roentgenographic changes supposedly diagnostic of the condition were not seen. In twelve patients, arthrotomy was avoided. They became asymptomatic and their bone scans returned to normal in a few months.     

Arthroscopy of the knee

Arthroscopy of the knee was first performed early this century. However, it became generally accepted and grew to be a major contributor to orthopaedic surgery only during the last two decades. It has improved our understanding of numerous knee pathologies and allowed us to treat many of these disorders with considerably less morbidity. But there remain areas that warrant attention. Training in arthroscopic technique needs to be intensified and our knowledge of knee conditions should be improved if we are to avoid certain pitfalls and complications during arthroscopic surgery. Another issue that must be addressed is the inappropriate use and abuses of arthroscopic surgery of the knee. Improved audit, that insist on photographic documentation of the lesion before and after treatment is suggested to curb this latter problem.     

Haemosuccus pancreaticus as a rare initial manifestation of chronic pancreatitis

Twenty-seven painful knee replacements were evaluated arthroscopically. The diagnostic and therapeutic value of these arthroscopic procedures was studied retrospectively. In 5 of the 27 cases, the arthroscopy revealed no diagnosis for the pain. Some form of arthroscopic treatment was performed in 20 cases; in 6 of these 20 cases, however, the treatment did not reduce the pain. Based on these findings, we conclude that the indications for arthroscopic evaluation and treatment of painful knee prostheses are limited.     

Ambulatory therapy of acute deep thrombophlebitis

A 53-year-old man developed deep vein thrombosis seven days after arthroscopic meniscectomy. He was successfully treated at home with a low-molecular-weight heparin followed by oral anticoagulation. Today, low-molecular-weight heparins are the initial treatment of choice for acute deep vein thrombosis. Due to the simplicity of administration, they have the potential for allowing home treatment. Several recently published randomised and controlled studies have demonstrated the feasibility, safety and efficacy of home treatment.     

A case of steroid-induced osteonecrosis of femoral condyle treated surgically

The clinical course and the established treatment for steroid-induced osteonecrosis of the femoral condyle have not been clarified yet, mainly because of the limited number of reports. Conservative treatment for steroid-induced osteonecrosis of the femoral condyle has been advocated, because the underlying disease tends to be serious and multiple joints are usually involved. Conservative treatment usually is continued until osteonecrosis becomes extensive and osteoarthritis has progressed enough to justify total knee arthroplasty. Reported here is a case of steroid-induced osteonecrosis of the lateral femoral condyle that, according to preliminary results, was treated successfully with a vascularized bone and periosteal graft.     

Histomorphological and immunohistochemical evaluation of joint changes in a model of osteoarthritis induced by lateral meniscectomy in sheep

OBJECTIVE: To evaluate the histomorphological and immunohistochemical changes induced in cartilages of ovine stifle (knee) joints 6 months after unilateral lateral meniscectomy. METHODS: Osteochondral sections were obtained from 8 distinct regions of knee joints of 6 adult Merino wethers that 6 months earlier had undergone lateral meniscectomy. Joint regions of 6 age matched sheep housed under identical conditions were used for controls. Serial sections were stained with toluidine blue or immunolocalized with monoclonal antibodies (Mab) 3B3(-), 7D4, and 5B10, which recognize epitopes on proteoglycans. RESULTS: In control joints the cartilage from the region of the tibial plateau not protected by the meniscus had significantly (p < 0.005) more structural abnormalities than other joint regions. After meniscectomy, only cartilages in the lateral femorotibial compartment showed histomorphological changes consistent with osteoarthritis (OA). The nature and severity of the lesions differed between the topographical regions within the joint. The most severe were found on the lateral femoral condyles and tibial plateaus. Reactivity with Mab 3B3(-), 7D4, and 5B10 was increased only in the lateral compartment cartilages, and was stronger in mild rather than moderate OA. CONCLUSION: Six month lateral meniscectomy in sheep produces histomorphological and immunohistochemical cartilage changes analogous to those described for early human OA and in other animal models. The severity and type of lesions obtained were dependent on the topographical joint location, but were most evident in cartilages from the lateral compartment.     

Proprioceptive deficits of the knee joint after rupture of the medial meniscus

We assessed knee joint proprioception in 23 patients with an isolated lesion of the medial meniscus. Thirteen patients were tested prior to their arthroscopic operation, and 10 patients were examined after partial arthroscopic resection of the injured meniscus. As a control group we evaluated 30 healthy volunteers with clinically inconspicious knee joints. For documentation of the proprioceptive capabilities we performed an angle reproduction test. Additionally the subjects were tested with and without an elastic knee bandage, to test the influence of such a bandage on knee joint proprioception. Our results showed that preoperatively proprioception was significantly less good than in the control group. We found no influence of the knee bandage on the proprioception of the injured knee. The postoperative group of patients showed significantly better proprioceptive capability than the preoperative patients. The postoperative results did not differ significantly from those of the control group.     

Active laboratory consultation for the clinical supporting system in the general hospital

OBJECTIVE: To study demographic, clinical, and radiographic staging patterns in patients with multifocal osteonecrosis to facilitate earlier diagnosis and optimize treatment. METHODS: Multifocal osteonecrosis was defined as disease of 3 or more anatomic sites. Patients were characterized demographically, which included disease associations, corticosteroid and other agent usage, presenting joints, and symptomatology. Radiographically, patients were evaluated with plain radiographs and magnetic resonance imaging (MRI) scans of all joints to determine the presenting stage of the lesions. RESULTS: We found that 32 of 1056 (3%) osteonecrosis patients under our care had multifocal disease. Associated factors included systemic lupus erythematosus (13 patients), inflammatory bowel disease (5 patients), malignancy (4 patients), and renal transplantation (3 patients). Thirty of the 32 patients (94%) had a history of corticosteroid therapy, with the other 2 patients found to have a coagulopathy. All 32 patients had bilateral femoral head involvement and 30 of 32 had bilateral knee involvement, with the other 2 having only left knee lesions. Osteonecrosis was also seen in the shoulder (28 patients), ankle (8 patients), and 3 other sites. Overall, 201 sites were involved (6.3 per patient). The majority of joints presented in a pre-collapse stage (77%). Patients most commonly presented with hip or multiple joint symptoms (22 patients, 69%). In 8 patients, the knee was the sole presenting symptomatic joint and the ankle and shoulder were the sole presenting symptomatic joints in one patient each. CONCLUSION: In patients with a diagnosis of osteonecrosis and complaints in other joints, these other areas should be fully evaluated with plain radiographs and, if inconclusive, with MRI. In patients with osteonecrosis not involving the femoral head, the patient's hips should be radiographically evaluated regardless of whether the patient is symptomatic. Patients diagnosed with osteonecrosis of the knee, shoulder, or ankle should have other joints evaluated, as such patients have multifocal disease roughly 50% of the time.     

Meniscal repair using the inside-to-outside technique

The frequent occurrence of degenerative joint disease following complete or partial meniscectomy is well recognized. Meniscal repair has been shown to lead to a lower prevalence of degenerative changes in the knee. Arthroscopically assisted inside-to-outside meniscal repair is a safe, reproducible technique for for salvaging the torn meniscus.     

Anterior cruciate ligament injury: fast spin-echo MR imaging with arthroscopic correlation in 217 examinations

OBJECTIVE: Our objective was to evaluate the accuracy of MR imaging strategy that uses primarily fast spin-echo sequences for the diagnosis of anterior cruciate ligament tears. MATERIALS AND METHODS: The original clinical interpretations of MR images of 217 examinations of the knee joint were correlated with subsequent arthroscopic results. Each MR examination included a double-echo fast spin-echo sequence as the only imaging sequence in the sagittal plane. Subsequent discordant MR and arthroscopic examinations were then subjected to reanalysis by two observers who were unaware of arthroscopic results to determine if misinterpretations were observer or image dependent. Two hundred sixteen patients who underwent MR imaging for suspected internal derangement of the knee subsequently underwent arthroscopic surgery. Two patients had both knees evaluated. One patient was excluded because he was referred for evaluation for osteomyelitis, not internal derangement. This yielded a total number of 217 MR examinations for suspected internal derangement of the knee. RESULTS: For 56 arthroscopically proven tears, the sensitivity of MR imaging was 96%. The specificity was 98%, yielding an overall accuracy rate of 98%. The positive and negative predictive values were 95% and 99%, respectively. These values are within the ranges of previously reported MR imaging strategies using conventional spin-echo sequences. CONCLUSION: Fast spin-echo MR imaging of the knee can be an alternative to conventional spin-echo imaging for the detection of anterior cruciate ligament tears.     

Arthroscopic debridement for osteoarthritis of the knee: a seven years follow-up study

We reviewed 32 knees with osteoarthritis of the knee treated by either arthroscopic debridement in association with drilling the subchondral bone or arthroscopic debridement alone and followed for 2.5 to 11 years. Eighteen knees had arthroscopic debridement and drilling the subchondral bone, and 14 knees had arthroscopic debridement alone. In the group treated with arthroscopic debridement and drilling the subchondral bone, 55.6% had good to excellent results, 22.2% had fair results, and 22.2% had poor results. In the group that had arthroscopic debridement alone, 57.2% had good to excellent results, 35.7% had fair results, and 7.1% had poor results. There was better relief of pain in the group with arthroscopic debridement alone.     

Neuroma of the sural nerve as a complication of stripping of the small saphenous vein

From 1989 to 1996, 61 patients, including 66 knees, aged 8 to 62, were diagnosed as mediopatellar plica syndrome of knee after arthroscopic examination. Twenty-one cases were misdiagnosed as medial meniscal lesions before arthroscopic examination. Fifty-nine patients (64 knees) underwent arthroscopic resection of the plicae and 2 patients underwent opened resection. Fifty-nine cases had an average follow-up of seven months. Fifty cases (54 knees) of them showed excellent and good results.