Osteochondritis dissecans of the medial femoral condyle associated with congenital hypoplasia of the lateral meniscus and anterior cruciate ligament

BACKGROUND/AIM: Blindness in the developed countries affects 3.5 million people. This study was conducted on the causes of blindness in the Republic of Ireland based on the register of the National Council for the Blind of Ireland. The aim was to determine the prevalence of potentially avoidable blindness and to identify its causes. METHOD: Criteria for registration as blind are in Ireland: best corrected visual acuity of 6/60 (0.1) or less in the better eye or a visual field restricted to 20 degrees or less. Data on 5002 adults 16 years an older registered as blind were analysed. The causes of blindness are classified in 17 diagnostic categories. RESULTS: The leading causes of blindness are macular degeneration and glaucoma, each accounting for 16% (812 and 795). Cataract accounted for 11% (561), a third of these had an associated cause of blindness and one tenth had a cognitive deficit. Diabetic retinopathy ranked as the 11th cause of blindness and accounted for 3% (147). More than half of the patients were 65 years and older. CONCLUSION: 25% of blindness was potentially avoidable. The treatable causes were glaucoma and diabetic retinopathy in the working population and glaucoma and cataract over 65 years of age. Glaucoma is the most important, which raises the question of a screening programme. The prevalence of blindness of 3% due to diabetic retinopathy is lower than in most other series.     

Five-year results of conservatively treated tears of the anterior cruciate ligament

Follow-up examinations of 35 patients with an arthroscopically confirmed isolated fresh tear of the anterior cruciate ligament were conducted after an average period of 5 years. After arthroscopy and immobilization of the knee in a plaster cast for 2 weeks, all 35 patients had been conservatively treated with neurophysiological physical therapy. Twenty-four of the tears were complete; the remaining 11 were partial. The results of the follow-up examination are based on subjective scores (O'Donoghue score, Lysholm score), an objective score (objective O'Donoghue score) and clinical examination. With the partial tears, good to satisfactory results were achieved, and surgery was needed less often. In these patients, it was largely possible to maintain the original level of athletic performance. Those patients with complete, isolated tears generally had satisfactory to poor results on the objective scores. There was a high rate of revision surgery, especially in the case of meniscus tears, and they were largely unable to regain their original level of athletic performance.     

Accuracy of direct signs of tears of the anterior cruciate ligament

OBJECTIVE: To evaluate the accuracy of direct magnetic resonance imaging (MRI) signs of tears of the anterior cruciate ligament. PATIENTS AND METHODS: Over the period April 1991 to February 1994, 92 consecutive MRI studies of the knee were obtained for which arthroscopic data were also available. The MRI studies were retrospectively evaluated for course, continuity, signal intensity, morphologic features, contour and visualization of the anterior cruciate ligament. Arthroscopic findings were correlated with individual primary signs and the overall MRI diagnosis. RESULTS: Among the cases studied were 4 partial and 32 complete tears of the anterior cruciate ligament (as determined by arthroscopy). Because of the low number of partial tears, it was not possible to draw any meaningful conclusions about the MRI diagnosis of this type of tear. For complete tears, the criteria with the highest accuracy were abnormal course of the ligament (96.0%) and high signal intensity (89.3%). The overall diagnostic accuracy of MRI was 98.8%. CONCLUSIONS: The most accurate direct MRI finding in patients with a complete tear of the anterior cruciate ligament was abnormal course of the ligament, followed by abnormally high signal intensity.     

Patterns of meniscal tears associated with anterior cruciate ligament lesions in athletes

In this study, 400 clinically anterior cruciate ligament (ACL) deficient knees were arthroscoped and studied prospectively in the period January 1986 to April 1992. An ACL tear was always confirmed, and 41 per cent of these patients did not have an associated meniscal tear. In 30.25 per cent the lateral meniscus was torn; in 21.25 per cent the ACL tear was associated with a medial meniscus tear, and in the remaining 7 per cent both menisci were torn. The most frequently associated meniscal injury was the bucket handle tear of the medial meniscus (9 per cent), followed by the posterior horn tear of the lateral meniscus, which showed the same frequency as the ragged (or degenerated) tear of the lateral meniscus (6 per cent). The horizontal tear of the posterior part of the lateral meniscus showed a prevalence of 4.3 per cent. This picture is probably dependent on a secondary referral nature of the centre surveyed, in which the average time between injury and arthroscopy was 23.3 months.     

Meniscal injuries associated with acute anterior cruciate ligament tears in alpine skiers

We reviewed the records of 315 patients receiving an arthroscopically assisted stabilizing procedure for an acute anterior cruciate ligament injury incurred while alpine skiing to evaluate associated meniscal injuries. Meniscal injuries were classified by type, location, and treatment of the tear. Of the 317 knees operated on, all demonstrated an anterior cruciate ligament tear at arthroscopy. Ninety-eight percent of the injuries (310) were diagnosed within 3 days of injury, and 97% (307) were reconstructed within 28 days of injury. All tears occurred in the intrasubstance of the ligament; 32% were isolated injuries and 68% were combined with other injuries. In 159 patients with 170 meniscal tears 141 of the tears (83%) were lateral and 29 (17%) were medial. The injury triad of anterior cruciate ligament-medial collateral ligament-lateral meniscus was seen nine times as often as the anterior cruciate ligament-medial collateral ligament-medial mensicus combination.     

The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients

We describe the results of conservative treatment for complete midsubstance tears of the anterior cruciate ligament (ACL) in 18 skeletally immature patients, followed for a minimum of 36 months. Six patients had an ACL reconstruction during the follow-up period and were assessed immediately before their operation. The average time from initial injury to evaluation was 51 months. All patients had symptoms when reviewed. The modified Lysholm knee score showed one excellent result, one good, eight fair, and eight poor with a mean score of 64.3. Only one patient had returned to her preinjury level of athletics. Secondary meniscal tears were confirmed in six patients, and three more had the clinical signs of a tear at follow-up. Radiological evidence of degenerative changes was found in 11 of the 18 patients. We conclude that the results of non-operative treatment for ACL injuries in this age group are poor and not acceptable.     

Technical considerations in the management of complex meniscus tears

Meniscal repair continues to be an important procedure in patients with meniscal tears. The orthopedic literature has recommended excision of complex tears or tears that are located in the central avascular region. For the past 13 years, the authors have repaired all meniscal tears that can be reduced anatomically and that have healthy tissue that will support the multiple sutures required for a stable repair, regardless of tear pattern or location. Correct patient selection criteria continue to be important. In all cases, the risks of complications and retear must be considered carefully and judged against the potential benefits of repair. A postoperative rehabilitation program that allows early range of motion, and progression of weight bearing is not detrimental to the healing process if the repair is stable. Close postoperative follow-up examinations are necessary to determine the incidence of meniscal symptoms; however, the absence of joint line pain, catching, locking, or effusion does not guarantee complete healing of the tear. Follow-up arthroscopy is currently the most accurate method to determine if complete or partial healing has occurred.     

Physiological and mechanical adaptations of rabbit medial collateral ligament after anterior cruciate ligament transection

Progressive physiological and mechanical changes in the medial collateral ligament of the adult rabbit were investigated for as long as 48 weeks after disruption of the anterior cruciate ligament. Eighty-one New Zealand White rabbits were separated into experimental, sham-operated control, and normal control groups. The experimental group underwent unilateral transection of the right anterior cruciate ligament, sham-operated animals served as controls for comparison, and normal animals were evaluated as age-matched, undisturbed (no surgery) controls. Blood flow to the medial collateral ligament (as a physiological measure) and mechanical function (structural and material properties) were assessed at 6, 14, and 48 weeks. The results indicated that loss of the anterior cruciate ligament leads to early mechanical deterioration of the medial collateral ligament with a corresponding loss of physiological homeostasis. Six to 14 weeks after the transection, values for cross-sectional area of the medial collateral ligaments rapidly increased to 1.5 times control values. The ligament became twice as large as the control ligament by 48 weeks. Concomitantly, medial collateral ligament stress at failure of the medial collateral ligament complex decreased rapidly 6-14 weeks after the transection and eventually fell to one-half that of controls by 48 weeks. In terms of low-load behaviour, laxity and load relaxation were significantly greater than that of controls 6 weeks after transection and were further increased by 14 weeks. By 48 weeks, laxity values had recovered somewhat and load-relaxation measures had recovered to near control values. At both 6 and 14 weeks, a statistically significant elevation in blood flow was demonstrated compared with controls. By 48 weeks, however, blood flow was no different from that of the sham-operated control. Thus, early after transection of the anterior cruciate ligament, both low-load and high-load mechanical properties of the medial collateral ligament deteriorated and the rate of blood flow was temporarily elevated. By 48 weeks, blood flow declined to near control values, with a corresponding recovery in viscoelastic behaviour. These findings suggest that, after transection of the anterior cruciate ligament, viscoelastic behaviour of the medial collateral ligament may be related to changes in blood flow and that restoration of normal flow patterns and vascular responses may be linked to the recovery of some low-load mechanical properties in the anterior cruciate ligament-deficient medial collateral ligament.     

A new technique for arthroscopic resection of a bucket handle tear

The authors present a previously undescribed technique for excision of a bucket handle tear. The technique uses a Caspari suture punch to pass a suture through the meniscus and use the suture as a tool to maneuver the meniscus so that its posterior horn attachment can be cut. The technique is noteworthy in that it eliminates the need for establishing an additional portal.     

Cyst of the medial meniscus: observation of two cases

The authors report two cases of cyst of the medial meniscus. In both cases imaging diagnostics, CT scan, or MRI allowed us to reveal the characteristic horizontal meniscal lesion that would be the primary cause of cystic degeneration of the meniscus. The two cases were treated by selective resection of the meniscal lesion and arthroscopic decompression of the cyst.     

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.     

Medial collateral knee ligament healing. Combined medial collateral and anterior cruciate ligament injuries studied in rabbits

BACKGROUND: Antineutrophil cytoplasmic antibodies (ANCA), particularly perinuclear ANCA (p-ANCA), have been found more frequently in sera from patients with ulcerative colitis (UC) than in sera from Crohn's disease (CD) or unclassified enterocolitis (UE) patients. This 2-center study examined sera from 102 pediatric patients with inflammatory bowel disease (IBD) to evaluate their diagnostic value and assess their relationship with disease features, distribution, activity and treatment. METHODS: The serum ANCA of 102 children with IBD were measured: 33 UC, 64 CD and 5 UE with various disease locations and degrees of activity. The mean age at the onset of symptoms was 10.7 years (1 to 16.3 years). Sera from 26 unaffected first degree relatives and 20 children without IBD were also investigated. ANCA were detected using indirect immunofluorescence of ethanol-fixed granulocytes. RESULTS: There were ANCA in the sera of 24/33 children with UC (73%), 9/64 with CD (14%) and 4/5 with UE (80%). p-ANCA were more frequent than cytoplasmic-ANCA in positive sera: UC = 67%, CD = 57% and UE = 75%. The presence of ANCA was 73% sensitive and 81% specific for a diagnosis of UC, compared to other IBD (p < 0.001). Three children with proved sclerosing cholangitis associated with UC were all positive. There was no link between ANCA-positive sera and disease activity, or other endoscopic or clinical criteria. ANCA were detected in 4/26 first degree relatives (15%) and in 1/20 control subjects (5%). CONCLUSIONS: Because of their sensitivity and specificity, ANCA may be helpful in the clinical assessment of patients with IBD, and especially those with UC. However, there is no link between the pressure of p-ANCA and the site of UC or its activity, so that it cannot be used to monitor medical treatment or surgical indications.     

Healing of the anterior attachment of the rabbit meniscus to bone

In a rabbit model the healing process of the anterior attachment of the medical meniscus was observed during the first 12 weeks after sharp transection and refixation in a tibial bone channel. Evaluations of the healing tissue were histologic analysis, application of immunohistochemical methods to show collagen types and nerve regeneration, and mechanical load to failure tests. Secondary changes to knee joint cartilage, as signs of eventual dysfunction of the refixed meniscus, were evaluated by analysis of proteoglycan fragment concentration in joint fluid and histologic analysis of knee joint articular cartilage and synovium. The healing tissue between the refixed attachment and bone matured from highly cellular, nonspecific granulation tissue at 1 week, to bone, fibrocartilaginous, and fibrous tissues, which at some sites developed an insertion specific tissue arrangement within a 12-week period. However, the irregular interface between the fibrocartilaginous tissue and the underlying bone, which is typical for a normal insertion, was not reestablished. Labeling for collagen Types I and II in the newly formed insertion did not return to normal. In addition a few collagen fibers connected the refixed attachment tissue to bone. New bone formation turned the initially cancellous bone tunnel walls into more solid cortical bone. However, new bone formation did not fill the distal part of the channel. The refixed meniscal attachment underwent necrosis and was revitalized by cell ingrowth from the periphery. Nerve fibers were found in the newly formed insertion by 12 weeks. The failure load at tensile testing never reached more than 20% that of a normal attachment. Degeneration of articular cartilage and increased proteoglycan fragment in the joint fluid were common after this procedure. These data suggest that, despite the focal appearance of insertion specific tissues and healing of collagen fibers to bone, the tissue architecture of a normal meniscal insertion and a normal meniscal joint protective function were not reestablished.     

The relationship between anterior cruciate ligament reconstruction tibial tunnel location and the anterior aspect of the posterior cruciate ligament insertion

OBJECTIVE: To assess the outcome of 31 patients treated in a day and semi-residential psychotherapy setting. METHOD: Patients had moderate to severe personality difficulties and were referred when current therapy was insufficient or because of the severity of their problems. Eighty-one percent had a Cluster C and 19% a Cluster B (Borderline) Personality Disorder diagnosis (DSM-III-R). Therapy was psychodynamically and feministin-formed and included a sociopolitical dimension. Rating scales used were the Symptom Checklist 90, Goal Attainment Scale, Global Assessment Scale and measures of health resource usage, which were completed pre-treatment, post-treatment and at 4-, 12- and 24-month follow-up. RESULTS: Mean duration of therapy was 4 months (68 therapy days). All clinical rating scales demonstrated marked improvements following treatment (p < 0.0001) which were sustained at 2-year follow-up. There were also improvements of health resource usage. CONCLUSIONS: The results document the clinical efficacy of psychotherapy in this setting, provide support for the philosophy of practice, and suggest that psychotherapy outcome can be evaluated at reasonable financial cost in many settings.     

Injuries of the medial collateral ligament and anterior cruciate ligament of the knee joint and Lemaire surgical functional treatment. Long-term outcome

The present paper reports the results of 112 extraarticular ligamento-plasties performed on the knee with the procedure proposed by Lemaire. The series includes isolated tears of the anterior cruciate and medical collateral ligament as well as combined tears of both ligaments. The clinical and radiological results with a mean follow-up time of 11.5 years are compared with the results obtained in a first assessment 8 years ago. Good clinical results are in contrast with increasing osteoarthrosis in 1/3 of the knees radiologically assessed. The operation for a torn anterior cruciate ligament should be performed as soon as possible to avoid secondary meniscal lesions with subsequent severe osteoarthrosis. Presence or absence of arthrotic signs in the X-rays mainly determine the long-term result after ligamento-plasties of the knee. The Lemaire plasties are well tolerated even by elderly still active people and need little postoperative care.     

Value of posterior cruciate ligament index in the diagnosis of anterior cruciate ligament injuries

Several EF-hand recoverin mutants were obtained and their abilities to bind to photoreceptor membranes and to inhibit rhodopsin kinase were determined. The mutants with the 'spoiled' 2nd, 3rd or (2nd+3rd) EF-hand structures did not act upon the kinase activity in the microM range of Ca2+ concentrations. Mutations of the 4th EF hand, which 'repaired' its Ca2+-binding activity, resulted in recoverin with three 'working' Ca2+-binding sites. The latter mutant inhibited rhodopsin kinase even more effectively than the wild-type recoverin, containing two working Ca2+-binding structures.     

MR appearance of anomalous insertion of the medial meniscus. A case report

We report on the MR imaging of an anomalous medial meniscus with a tear in a 41-year-old man. Anomaly of the medial meniscus is rare and difficult to diagnose clinically. The MR images contributed to the pre-arthroscopic diagnosis and arthroscopy confirmed the lesion. The anomalous meniscus was not related to the symptoms.     

Functional testing in the anterior cruciate ligament-deficient knee

Functional testing of patients with anterior cruciate ligament (ACL) deficient knees and normal subjects during stressful activities such as running to a cut and running to a stop and during activities common to daily life, such as walking, stair climbing, and jogging, is presented. Analysis focused on the application of these tests to treatment planning and clinical evaluation. Functional testing during stressful activities indicates that some patients with ACL-deficient knees have higher than normal net hamstring moments during the early phase of these activities. These results suggest dynamic muscular substitution using the hamstrings in patients with chronic ACL-deficient knees. Patients tested during less stressful activities, such as walking and stair climbing, also demonstrated substantial differences from ACL-intact subjects. The majority of patients tended to reduce the net quadriceps moment when the knee was near full extension. Approximately 75% of the patients who were ACL-deficient developed this type of adaptation, which appears to be a subconscious method of avoiding the net anterior pull of the quadriceps mechanism when the knee is near full extension. Functional testing of the ACL-deficient knee provides meaningful information that cannot be obtained by simpler clinical tests. This information can be extremely useful in the selection and evaluation of patients with certain treatment modalities, since it seems to be directly related to some patients' ability to functionally adapt to the loss of the ACL.