Biomedical subjects
Publications and source records attributed to D J Dandy.
Seventy-six knees with fracture-separations of articular cartilage are described. The lesion involved the full thickness of the articular surface with exposed subchondral bone in 28 knees and only part of the thickness in 48. The clinical features and distribution of the lesions within the knee are described.
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Thirty-nine patients underwent reconstruction of the anterior cruciate ligament with carbon-fibre and a MacIntosh repair; all had a negative pivot shift test after operation. Some patients had persistent pain, mild effusion and synovial thickening; in 10 of these patients the symptoms warranted arthroscopic examination and biopsy at a mean of 16.9 months after the repair. Arthroscopy revealed that the carbon-fibre had not induced the formation of a "new ligament" and that the repair was merely covered by a thin, fibrous sheath. Histological investigations confirmed this finding, with only a suggestion of a fibroblastic response to carbon-fibre found in two patients. Particles of carbon-fibre were found scattered through the knees. Synovitis and breakdown of the skin over subcutaneous carbon-fibre complicated treatment. Failure of the carbon-fibre to bond to bone was detected radiographically.
The results of three different types of meniscectomy have been compared in 219 knees, 71 treated by arthroscopic partial meniscectomy, 45 treated by open partial meniscectomy, and 103 treated by open total meniscectomy, with a mean follow-up of 4.3 years. Knees which had undergone previous operations or had other simultaneous operative procedures or ligamentous damage were excluded. Knees with chondromalacia were included provided that this did not amount to frank osteoarthritis. Simple indicators were used for the rate of early recovery from the operation, and the Tapper and Hoover scale was used to record the symptomatic results in the longer term. It was found that knees treated by arthroscopic partial meniscectomy did considerably better than the others by all the criteria used. In most parts of the study there was a clear gradation between the results of the three types of treatment: arthroscopic techniques did better than open operations, and partial meniscectomy did better than total meniscectomy.
In the first 1000 arthroscopic operations performed by one surgeon 136 patients had two or more procedures, making a total of 1168 during the 1000 operations. The indications for operation were internal mechanical derangements in 565 patients, anterior knee pain in 246, disorders of the synovium in 77, ligament injuries in 63, and degenerative joint disease in 49. Complications included fracture of instruments in the knee in five patients, haemarthrosis in 10, deep vein thrombosis in three, and synovial fistula in one. In no patient was the wound infected. A total of 26 different operations was performed.
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There are many perfectly satisfactory ways to remove bucket handle meniscal fragments under arthroscopic control, and there is nothing to be achieved by arguing the relative merits of dividing the back end before the front, the central approach or the anterolateral, or the role of the operating arthroscope. In my experience, the method described has proved reliable, simple, and quick, with an average operating time in the range of 20 minutes. Additional advantages are that the technique requires only simple hand instruments and that the formalized step-by-step approach makes both learning and teaching of the technique more straightforward. Although this technique has many advantages, it is not universally effective; there are times when it must be modified or another approach used instead, and other surgeons may find that other techniques suit the better. If there is a single "secret" of arthroscopic surgery, it is that the surgeon should have at his or her command a wide variety of arthroscopic approaches and techniques and be thoroughly confident in basic arthroscopic skills before attempting arthroscopic surgery. As in other fields of orthopedic surgery, technical success is based upon careful planning and the proper use of simple instruments handled correctly and precisely.
Detailed analysis of a series of 99 arthroscopic partial meniscectomies with a minimum follow-up time of 2.1 years (mean, 3 years; maximum, 4.5 years) showed that the spectacularly good early results were maintained in the longer term. Group I knees (67) had no previous surgery or ligamentous insufficiency, but those with chondromalacia were included. The remaining knees were designated Group II and analyzed separately. Group I showed 51.5% excellent and 39% good results, using criteria based on those of Tapper and Hoover. When only results in bucket handle tears were considered, 73% were excellent and 19% were good. Results in Group I also depended on the presence or absence of chondromalacia. Results in Group II were poorer than in Group I, but were still satisfactory in 67% of knees, although many had a torn anterior cruciate ligament of frank osteoarthritis. The arthroscopic technique should, where possible, become the standard method of treatment if patients require meniscectomy.
There four indications for arthroscopy in patients with ruptures of the anterior cruciate ligament: (1) assessment of the acutely injured knee, which will usually have a hemarthrosis; (2) assessment of the knee with late symptoms following ligament injury; (3) a preliminary to ligament reconstruction to assess the integrity of the menisci; (4) the assessment of patients who have symptoms following ligament reconstruction. Many patients achieve a good result after arthroscopic correction of meniscal lesions and other derangements without ligament reconstruction. Repair of all acutely ruptured anterior cruciate ligaments will result in many unnecessary ligament repairs. Assessment of acute ligament repairs is made difficult by the absence of a controlled series. The criteria for distinguishing those patients who need ligament reconstruction from those who will do well with aggressive conservative management alone have yet to be established. A prosthetic ligament can be inserted under arthroscopic control without arthrotomy, but no suitable prosthetic material is yet available.
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A series of 622 patients treated at Newmarket General Hospital for injuries resulting from contact with horses was studied. The types of injury and the manner in which they were sustained were analysed.