Biomedical subjects
Publications and source records attributed to D J Dandy.
Thirty-eight intra-articular ganglia were found in knees that were painful or had the symptoms of a mechanical derangement. During the period of study, 6,500 knees were examined arthroscopically by one surgeon. Thirty-five of the ganglia arose at the insertions of the cruciate ligaments. Excision of the ganglion yielded excellent results in 22 knees, good in 14, and fair in one.
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Nine pedunculated benign synoviomata causing mechanical symptoms similar to those of a torn meniscus are described. The average age of the patients was 34.4 years. During the period of study, 2254 meniscal lesions causing mechanical symptoms were identified, giving an incidence of one benign synovioma for every 250 meniscal lesions. All the lesions were removed arthroscopically with relief of symptoms.
The anatomy of 1000 symptomatic meniscus lesions is described and related to the age of the patients. All symptomatic lesions found during the study period were treated by arthroscopic surgery. Meniscal lesions were commoner in the right knee (56.5%) and 81% of the patients were men. Of the medial meniscus tears, 75% were vertical and 23% horizontal. Vertical tears of the medial meniscus occurred most often in the fourth decade and horizontal tears in the fifth. There were 22% type I, 37% type II and 31% type III vertical tears; 62% of type I tears and 23% of type II tears had locked fragments. Superior flaps were six times more common than inferior flaps. Of all medial meniscus fragments, 6% were inverted; 51% of these were flaps and the rest ruptured bucket-handle fragments. Of the lateral meniscus lesions 54% were vertical tears, 15% oblique, 15% myxoid, 4% were inverted and 5% were lesions of discoid menisci. The commonest pattern of tear in the lateral compartment (27%) was a vertical tear involving half the length and half the width of the meniscus.
We reviewed 41 knees after arthroscopic lateral release for recurrent dislocation of the patella at a mean follow-up of four years, and graded the results according to the criteria of Crosby and Insall (1976). There were no dislocations after operation in 28 knees (68%); the less satisfactory results were in patients with subluxation of the patella on extension of the knee and those with generalised ligamentous laxity. There were no complications. A characteristic and previously unreported lesion of the patellar surface was seen in eight of the 41 knees. The results of lateral release are better than those reported for other techniques. This treatment, by either open or arthroscopic methods, is recommended.
We examined the menisci in 47 patients at the time of anterior cruciate ligament reconstruction. Twenty-one patients had abnormal menisci at a mean of 34 months after injury, but there was no difference between the Lysholm scores of patients with intact or damaged menisci. Eleven patients had a new meniscal injury between reconstruction and review at a mean of six years later; only 15 patients had both menisci intact nine years after injury. If pivot shift had been cured, the incidence of meniscal injury was reduced, but remained higher than normal. If pivot shift returned after reconstruction there was a significantly higher incidence of meniscal injury. Meniscal lesions appear to be the result of instability and not the cause.
We report two patients with permanent dislocation of the proximal tibiofibular joint and no history of trauma. Both needed operation, one for persistent pain and the other for common peroneal nerve involvement, and both had a good result.
We report the results of arthroscopic removal of loose bodies and abnormal synovium from 18 knees with primary synovial chondromatosis. After a mean of three years, six months (range one to 10 years), 14 knees were either symptom-free or had only minor symptoms. Three of these had required two arthroscopic operations. Three patients were improved but not cured and there was one failure. The results were better than the published results of open operation for this condition. Three patterns of macroscopic appearances were noted: four knees had large lesions covered by normal synovium, 10 had small fragments of cartilage lying in or on the synovium and four had only free fragments of cartilage in the joint cavity but none in, on, or under, the synovium. These three appearances may represent three different disease processes.
We reviewed lesions of the femoral condyles seen in 5,000 knee arthroscopies, recording the findings and the age and sex of the patients. We were able to distinguish the characteristics of developing and late osteochondritis dissecans, acute and old osteochondral fractures, chondral separations, chondral flaps and idiopathic osteonecrosis, and suggest that these are separate distinct conditions. Haemarthrosis was associated only with acute osteochondral fractures. The characteristic feature of osteochondritis dissecans was an expanding concentric lesion at the 'classical' site on the medial femoral condyle which appeared during the second decade of life and progressed to a concave steep-sided defect in the mature skeleton. Caffey's (1958) classification of epiphyseal dysplasias could not be applied to osteochondritis dissecans, which appeared to have a gradual onset without acute trauma. Much of the controversy about the cause of osteochondritis dissecans is the result of imprecise nomenclature.
We report the arthroscopic drilling of classical lesions of osteochondritis dissecans in 11 knees in 10 children with at least six months history and no sign of clinical or radiological improvement. There were eight boys and two girls and the average age at operation was 12 years 11 months. Relief of pain was noticed within days of operation; radiological healing occurred within 12 months in nine of the 11 knees.
Forty-seven patients with disabling instability due to isolated anterior cruciate deficiency are described. None had responded to conservative measures or to attempted correction of internal derangements. Eighteen patients were treated by extra-articular MacIntosh lateral substitution alone, the other 29 were treated by the same procedure combined with carbon-fibre replacement of the anterior cruciate ligament. No statistically significant difference was found between the two groups at six years. A satisfactory outcome was found in 44% of the extra-articular group and 55% of the carbon-fibre group at last review; however, the latter group had more complications. There was a marked deterioration in the quality of results between three and six years in both groups.
Two groups of patients with chronic, symptomatic anterior cruciate ligament deficiency were reconstructed with carbon fibre. In 15 patients, the prosthesis was inserted through an anterolateral arthrotomy; in 14, it was inserted arthroscopically. Both groups also received a MacIntosh extraarticular lateral substitution. Assessment included subjective functional rating and objective clinical examination for instability. No significant difference in subjective functional rating was present after a minimum of 5 years; however, a reduced complication rate and diminished return of clinical instability was evident in the arthroscopic group during this period. Reconstruction was satisfactory in 47% of the arthrotomy group and 64% of the arthroscopy group when subjective and objective criteria were combined to assess the final outcome. This study supports the proposition that, in combination with extraarticular lateral substitution, arthroscopic insertion of cruciate prostheses compares favourably with conventional "open" techniques.
Thirty-three patients with undiagnosed chronic knee pain had features of autonomic disturbance. Thermography is a useful imaging technique for demonstrating this abnormality. The patients lacked the thermographic symmetry observed in 16 normal controls but this returned with resolution of the pain. Recognized radiological and scintigraphic features of algodystrophy were found. The long duration of symptoms, high proportion of young females and the severity of the associated disability were notable. It is suggested that algodystrophy is a more frequent cause of chronic knee pain than previously recognized. Autonomic abnormalities may be less intense in disease at this site, particularly in young females and may be overlooked. This characteristic of algodystrophy of the knee may contribute to chronicity and subsequent disability.
Human synovial tissues have been assayed for the production of cartilage degrading activity (CDA). This activity is thought to be homologous with catabolin/interleukin 1 (IL1) produced by porcine synovium and leucocytes and by human leucocytes. The CDA of 26 rheumatoid (RA) and 41 non-rheumatoid synovia was measured on a dry weight basis. The rheumatoid synovia showed a threefold increase in activity over the non-rheumatoid, but there was no significant overall difference on a deoxyribonucleic acid (DNA) basis. The rheumatoid synovia appeared to consist of two populations; in over half the samples CDA was not related to cellularity, but eight patients had a high CDA and a high cellularity.
Osteoid osteoma at the knee is a rare condition. The literature is reviewed, and a patient is reported in whom a lesion communicating with the knee joint was removed arthroscopically. The diagnosis was made histologically and review of the radiographs revealed the lesion.
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Arthroscopy plays an important role in diagnosis in the management of anterior knee pain and may be used for treating the underlying pathology.