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.     

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.     

The effect of tourniquet release time on the analgesic efficacy of intraarticular morphine after arthroscopic knee surgery

A randomized, controlled study was conducted in patients undergoing elective arthroscopic knee surgery to assess the effects of tourniquet release time on analgesia after intraarticular (I.A.) injection of morphine. Standardized general anesthetic and surgical techniques were used for all patients, including a thigh tourniquet inflated at pressures between 300 and 350 mm Hg. At the conclusion of the arthroscopic procedure, 5 mg morphine in 25 mL saline was administered I.A. Patients were then randomized to one of two treatment groups. In Group 1 (n = 20), the tourniquet was kept inflated for 10 min after I.A. injection, whereas in Group 2 (n = 20), the tourniquet was deflated immediately after I.A. injection. Postoperative pain was assessed using a visual analog scale in the recovery room when the patients were awake and at 2, 4, 6, 8, and 24 h after I.A. injection. Patients who complained of pain in the recovery room received increments of intravenous meperidine 25-50 mg. On discharge from the recovery room, patients received oral mefenamic acid 250-500 mg for pain relief. The time and quantity of analgesics required were recorded. Patients in Group 1 had significantly (P < 0.05) lower pain scores than those in Group 2 at 2, 4, 6, and 8 h postoperatively. These low pain scores were associated with lower requirements of supplementary analgesics. We conclude that, as compared with releasing the tourniquet immediately after I.A. injection of morphine, maintaining the tourniquet inflated for 10 min provides superior analgesia and decreases the need for supplemental analgesics.     

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.     

Tramadol (Tramal) in the treatment of rheumatic diseases-- comparative study

In order to evaluate the efficacy of centrally acting analgesics. In treating rheumatic diseases, tramadol hydrochloride (Tramal Grunental) has been administered to a group of 68 patients (36 women and 32 men), who received 100 mg twice a day during a 10-day treatment. The testing comprised 14 female patients with rheumatoid arthritis, 20 patients (7 women and 13 men) with degenerative (OA) hip and knee diseases and 34 patients (15 women and 19 men) affected by the vertebrogen painful syndrome of lumbar spine. The control group comprised 12 patients (9 women and 3 men) with rheumatoid arthritis using non-steroidal antiinflammatory drugs only, 22 patients (12 women and 10 men) with the OA of the hip and knee, using paracetamol only, and 30 patients (15 women and 15 men) affected by the vertebrogen painful syndrome of lumbar spine, also using paracetamol only. The visual analogue scale has been used in following the pain relief assessments during the therapy. It has thus been observed that the intensity of pain has not been significantly relieved with the acute rheumatic diseases (p > 0.05) in the control group either; that the significant pain relief has occurred with the degenerative (OA) rheumatic diseases (p < 0.05) but not in the control group; while the best analgetic effect of tramadol has been proved on the patients affected by the vertebrogen painful syndrome of lumbar spine (p < 0.01) but was not significant in the control group. During the therapeutic treatment 13 patients (19%), mostly the elderly, experienced side effects, manifested as nausea and the dry mouth.     

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.     

Effects of stress inoculation training on athletes' postsurgical pain and rehabilitation after orthopedic injury.

The efficacy of a cognitive-behavioral intervention ( stress inoculation training; SIT ) for postsurgical anxiety, pain, and physical rehabilitation in injured athletes was tested. Sixty male athletes who underwent arthroscopic surgery for miniscus injury in 1 knee were randomly assigned to either treatment (SIT and physical therapy) or control (physical therapy only) conditions. Results showed that participants in the treatment group demonstrated significantly less postsurgical pain and anxiety during the rehabilitation process, compared with controls. Additionally, treated participants required fewer days to return to criterion physical functioning, compared with nontreated participants. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Access to alcohol from licensed premises during adolescence: a longitudinal study

Sixty-two consecutive patients with painful limited dorsiflexion of the ankle not responding to nonoperative treatment participated in a prospective study. All 42 men and 20 women (average age, 31 years) underwent arthroscopic surgery. Preoperative radiographs were graded according to an osteoarthritic and an impingement classification. Standardized followup took place at 4 months and 1 and 2 years after surgery. Results showed that the degree of osteoarthritic changes is a better prognostic factor for the outcome of arthroscopic surgery for anterior ankle impingement than size and location of the spurs. The hypothesis is that osteophytes without joint space narrowing are not a manifestation of osteoarthritic changes but rather the result of local (micro)trauma. After 2 years, 73% of the patients experienced overall excellent or good results; 90% of those without joint space narrowing had good or excellent results, and 50% of those with joint space narrowing had good or excellent results. At the 2-year followup, the group without joint space narrowing showed significantly better scores in pain, swelling, ability to work, and engagement in sports. This study also revealed that patients with less than 2 years of ankle pain before surgery and spurs located anteromedially were more satisfied with the outcome than when longer periods of preoperative pain were involved and when spurs were located anterolaterally.     

Symptomatic intraarticular ganglia of the cruciate ligaments of the knee

This case report draws attention to the clinical presentation, differential diagnosis, and recommended diagnostic modality and treatment of symptomatic ganglia of the anterior and posterior cruciate ligaments. One patient presented with a recurrent inability to fully extend the left knee. Another patient presented with pain and soreness over the lateral aspect of the knee, including the lateral joint line. The diagnosis of ganglia of the cruciate ligaments was made after clinical, radiographic, and magnetic resonance examination. Both patients were treated successfully with resection of their ganglia using arthroscopic techniques.     

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.     

Surgical treatments for orthopaedic complications in long-term haemodialysis patients--a review of 546 cases over the last 8 years

We reviewed 546 operative cases in haemodialysis patients during the past 8 years between June 1990 and May 1998. The average age of the 257 male and the 289 female patients was 57.1 years. The average period of haemodialysis was 14 years and 4 months. We discussed the etiology, pathological focus, frequency, symptoms, problems and operative indications. Carpal tunnel syndrome occurred most frequently, occupying 289 cases. Short-term postoperative results were positive in the initial case within 6 months after the occurrence of the first symptoms. Because no effective method preventing recurrence existed, synovectomy was used as much as possible in the initial operation. Surgical treatment was used for amyloid arthropathy in 15 shoulders. It was effective in cases resistant to any conservative treatment. For the knee joint, the arthroscopic synovectomy was performed in 8 cases, and total knee replacement in 6 cases. The results of the total knee replacement cases were good. However, recurrences were observed in 40% of the synovectomy cases. In the hip joint, the curettage and bone grafting were performed in 7 hips of 6 patients. All bone grafts were consolidated and there was no case of postoperative pathological fracture. In some cases with destructive spondyloarthropathy, the vertebrae involved spontaneously fused without severe kyphotic deformity. A case with mild pain and without neurological deficit can be treated conservatively. A case with severe pain, instability, and myelopathy indicates operative measures must be taken. Attention must be paid for a possible collapse of the grafted bone after the cervical level two anterior fusion. Haemodialysis patients are vulnerable to infection. This diagnosis is difficult to distinguish due to the weakened state of the immune system. Rigorous attention is required to prevent and detect infection in cases using artificial joints or instrumentation. The treatment of bone and joint disturbances from dialysis-related amyloidosis has become surgical due to the advancement of dialysis control. However, it remains one of the more conservative treatments. Determining the cause and establishing a method of treatment are desired as early as possible.     

Glycine-glutamate interactions at the NMDA receptor: role of cysteine residues

The term "centrocentral anastomosis" is used to describe the end-to-end connection across interposed nerve grafts between paired fascicular groups of the proximal stump of a severed nerve. In 22 patients harboring a painful terminal neuroma following amputation of a lower limb (20 neuromas on the sciatic nerve and two on the peroneal nerve), a centrocentral anastomosis was performed on the end of the sectioned nerve to treat pain that had not improved with conventional conservative treatment. Follow-up review at 1 year revealed that the typical neuroma pain had disappeared in all cases, although sporadic diffuse pain persisted in four. Where previous phantom sensation was present, no change was observed. The results presented here are consistent with laboratory findings demonstrating the absence of neuroma formation after centrocentral anastomosis. Therefore, this technique is recommended for the treatment of painful amputation neuroma.     

Minimally invasive osteosynthesis of fractures of the tibial head

The role of closed reduction techniques in tibial plateau fractures was evaluated retrospectively in a group of 33 patients. The patients had mainly B fractures (AO classification) and were treated by the arthroscopic reduction technique (n = 10) or by reduction under fluoroscopic control (n = 23) and transcutaneous screw fixation. The 21 patients with an average follow-up of 34 months (minimum 1 year) were reviewed. Using clinical and radiological criteria, 19 results were considered excellent to good. One patient with a residual deformity was revised with a total knee and 1 patient with an anatomical result had arthritic pain in the knee operated on. Arthroscopic reduction had no advantages over reduction under fluoroscopic control in this study. The specific value of the technically demanding endoscopic procedure should be questioned, as percutaneous reduction under fluoroscopic control may achieve comparable results in the majority of these cases.     

The prevalence and related symptomatology of Helicobacter pylori in children with recurrent abdominal pain

The plicae are synovial septa remaining in adult life that existed in early fetal life. The suprapatellar plica separates the suprapatellar pouch from the knee joint. The plica syndrome has clinical significance, which has been occasionally overlooked, but the pathophysiology of symptomatic plicae may be hard to explain. To evaluate the clinical significance of the suprapatellar plicae, the authors reviewed 34 cases in 23 patients with vague pain around the knee and a total septum of the suprapatellar plica at arthroscopic examination from September 1991 to December 1993. The follow-up period was from 6 months to 2 years and 9 months. The most common presenting symptom was chronic mild knee pain, aggravated by prolonged squatting or standing, with other patients reporting recurrent swelling, instability, giving-way, or a feeling of snapping. The objective findings include palpable band on the superomedial side, audible snapping, and local tenderness, but there were no significant abnormal findings in the laboratory. The radiographic findings were few, with sclerosis of the articular surface of the patella in 2(6%), malalignment in 1(3%), and mild degenerative change in 4 cases(12%). Five of 11 patients evaluated by bone scan had increased uptake around the patellofemoral joint, and 7 of 13 knees had a relatively small suprapatellar bursa on conventional arthrogram or pneumoarthrogram. At arthroscopy, a suprapatellar plicae with complete septum was identified in 30 of 34 cases (88%) and associated lesions presented as meniscal tears, loose body, and discoid meniscus without tear. The complete plicae were surgically excised under arthroscopic control in 30 patients and the results were excellent in 22 patients (73%), good in 5 (17%), and poor in 3 (10%)at 17 months follow-up; there were no failures. In our opinion, the complete suprapatellar plica is clinically significant in patients who have equivocal diagnosis of knee problems and further studies of the pathophysiology of complete suprapatellar plica are needed.     

Carbon-fiber implants for knee ligament reconstruction. 10-year results

The retrospective results of carbon prostheses for knee ligament reconstruction in 120 patients, as established by questionnaire, are reported at 10 +/- 2 years follow-up. Eighty patients could also be reviewed clinically. Some 60% of the patients showed good subjective function at reduced activity level. Complications were seen in 72.5% of the patients with rupture of the carbon prosthesis and in 68% of those with synovitis. X-ray showed osteoarthritis in up to 59% of the patients. Carbon prostheses for collateral ligament reconstruction (85% medial, 5.8% lateral) were successful in 75% of cases. Activity and time seem to be less responsible for failure of the carbon prostheses than the features of growing in. Destruction of the knee joint over time is due to reactive synovitis and catabolic enzyme reaction and correlates with joint effusion and pain. If these problems appear, (arthroscopic) resection of the synovia is indicated to interrupt the circulus vitiosus.     

Ligament injuries of the ankle--what happens later? Non-surgical treatment is effective in 80-90 per cent of cases

Ligament injuries of the ankle joint are the most common sports-related injuries. In more than 90 per cent of all cases, it is a question of lateral ligament injury. The recommended acute treatment is always non-surgical, with range of motion training, followed by strengthening and co-ordination exercises. Approximately 80-90 per cent of all ligament injury patients regain normal ankle function after this form of treatment. Early active treatment can reduce time off from sports and the duration of sick leave. Residual problems, mainly pain or recurrent or chronic instability are seen in approximately 10-20 per cent of cases. In cases of chronic instability, ligament reconstruction is recommended. In patients with anterior or anterolateral ankle pain, arthroscopic resection of bone spurs or loose bodies may be beneficial.     

Current principles of multidisciplinary treatment of pain in orthopedic clinics

Differentiated strategy of treating patients with acute and chronic pain is developed. Preemptive analgesia is a priority trend in the treatment of acute postoperative pain. The most prevalent method of postoperative analgesia is prolonged opioid epidural analgesia carried out in intensive care wards and other wards by an acute pain management team. For treating patients with chronic painful syndromes, protocols of initial clinical and diagnostic evaluation are developed, permitting the choice of individual treatment strategy. Differentiated complex drug therapy planned with consideration for individual course of the painful syndrome is the basis of treating patients with phantom pain syndrome. Algorithms of differentiated therapy of radicular and spondylogenic pain are designed. Stage-by-stage analysis of treatment efficacy is carried out using modern electrophysiological methods. Realization of the proposed organization principles improved the efficacy of postoperative analgesia to 88.2%, prevented the development of postoperative painful syndrome in 35.6% cases, decreased the incidence of phantom pain syndrome after amputation of the limb from 63.3 to 31.6% and increased the efficacy of this syndrome treatment to 70.1%, and increased the efficacy of treating vertebrogenic painful syndromes to 82.3%.     

Flexion instability after primary posterior cruciate retaining total knee arthroplasty

Between 1990 and 1995, 25 painful primary posterior cruciate ligament retaining total knee arthroplasties were revised for flexion instability. These patients shared typical clinical presentations that included a sense of instability without frank giving way, recurrent knee joint effusion, soft tissue tenderness involving the pes anserine tendons and the retinacular tissue, posterior instability of 2+ or 3+ with a posterior drawer or a posterior sag sign at 90 degrees flexion, and above average motion of their total knee arthroplasty. The primary total knee arthroplasty was performed for osteoarthritis in 23 patients and rheumatoid arthritis in two patients. There were 13 male and 12 female patients and their mean age was 65 years (range, 35-77 years). Before the revision operation, Knee Society knee scores averaged 45 points (range, 17-68 points) and function scores averaged 42 points (range, 0-60 points). Twenty-two of the knee replacements were revised to posterior stabilized implants and three underwent tibial polyethylene liner exchange only. Nineteen of the 22 knee replacements revised to a posterior stabilized implant were improved markedly after the revision surgery. Only one of three knee replacements that underwent tibial polyethylene exchange was improved. After the revision for flexion instability, Knee Society knee scores averaged 90 points (range, 82-99 points) and function scores averaged 75 points (range, 45-100 points) for the 20 knees with a successful outcome. This study suggests that flexion instability can be a cause of persistent pain and functional impairment after posterior cruciate ligament retaining total knee arthroplasty. A revision operation that focuses on balancing the flexion and extension spaces, in conjunction with a posterior stabilized knee implant, seems to be a reliable treatment for symptomatic flexion instability after posterior cruciate retaining total knee arthroplasty.     

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.