Biomedical subjects
Publications and source records attributed to K E DeHaven.
Meniscal tears are common sports injuries. This article details the clinical evaluation of the athlete presenting with knee pain. Conservative (nonoperative) treatment and arthroscopic procedures are discussed.
Fifteen patients who had sustained a rupture of the Achilles tendon were managed non-operatively with use of a functional bracing protocol, and clinical and functional performance measures were assessed after a mean duration of follow-up of thirty-one months (range, twenty-four to forty-five months). An age and gender-matched group of fifteen subjects was assessed to provide normative data for the comparison of side-to-side differences. Numerical scores were generated on the basis of subjective responses to a questionnaire, clinical measurements of the range of motion of the ankle and the circumference of the calf, and the results of the Thompson squeeze test and a single-limb heel-rise test. A 100-point scoring system was used to categorize the outcome as excellent, good, fair, or poor. In addition, ground-reaction forces and temporal data were assessed during functional dynamic activities that included walking, a single-limb power hop, and a thirty-second single-limb heel-rise endurance test. The result was graded as excellent for three patients, good for nine, fair for two, and poor for one. An increase in passive dorsiflexion of the treated ankle was the only clinical measure that was significantly different between the groups (p = 0.02). This increase in dorsiflexion was positively correlated with vertical force output between the mid-stance and terminal-stance phases of gait (r = 0.40, p = 0.05). With the numbers available, we could detect no significant differences between the groups with regard to the kinetic or temporal variables that were measured during functional dynamic activities. Patients who generated less peak vertical force and vertical height during the single-limb power-hop test tended to have poorer clinical scores. We believe that non-operative functional bracing may prove to be a viable alternative to operative intervention or use of a plaster cast for the treatment of acute ruptures of the Achilles tendon. The goals of treatment are to prevent the musculoskeletal changes that are associated with immobilization, to reduce the time needed for rehabilitation, and to facilitate an early return to work and to preinjury activities.
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Concomitant ACL and meniscal tears pose a higher risk for premature osteoarthritis than either condition alone, especially in the active athlete. Given that the ACL-deficient knee is also at risk of initiating tears and propagating smaller tears, ACL reconstruction is advisable. The meniscal repair in the ACL-unstable knee is at a higher risk for retear. Therefore, ACL reconstruction should be considered seriously for the ACL-deficient patient with a reparable meniscal tear, as well as for the irreparable meniscal tear, as long as the patient is an otherwise appropriate reconstruction candidate. The meniscal tear with a vertical longitudinal pattern that is less than 5 mm from the meniscosynovial junction and longer than 10 mm should be repaired. Tears with rim widths greater than 5 mm may be repaired if there is evidence for vascularity. Those tears that have rim widths greater than 5 mm without evidence for significant vascularity may be repaired, but healing enhancement techniques are recommended, including rasping of synovial fringes and insertion of fibrin clot, and both the patient and the surgeon need to be aware of the significantly lower success rates. If repairs of double flap, double longitudinal, or radial tears are performed, then use of the fascia sheath coverage with fibrin clot, as proposed by Henning et al, can be considered. Partial meniscectomy is acceptable for the complex meniscal tear.
Stable partial-thickness tears, longitudinal tears of less than 5 mm length and short (5 mm or less) radial tears can sometimes be left alone. Tears known to be definitely repairable are traumatic longitudinal tears within the vascular zone of the meniscus with minimal damage to the meniscus body fragment. When an attempt is to be made to repair tears in the avascular zone, it is necessary to utilize healing-enhancement techniques such as synovial fringe rasping and fibrin clot insertion. The survival rate for repaired menisci at a minimum follow-up time of 10 years was 79% in the author's cases. Intermediate (5 year) results after partial meniscectomy show a diminished incidence of post-surgical degenerative changes when compared to total meniscectomy.
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Localized pigmented villonodular synovitis is a rare condition of the knee that can present with symptoms suggesting internal derangement. We report a case of a patient who presented with signs and symptoms of a loose body in the knee. The lesion was treated with resection using arthroscopic cautery.
As the importance of meniscal preservation has become recognized, meniscal repair has become a more commonly practiced procedure. We briefly review the current, commonly accepted indications, techniques, and our rehabilitation protocol for meniscal repair. Both open and arthroscopic repairs are reviewed, including the arthroscopic techniques classified as inside-out, outside-in, and all inside. We conclude with a review of the results of meniscal repair and some thoughts on future directions.
As noted through the work of Fairbank, total meniscectomy is not a benign operation. Cox et al found that meniscectomies in canine knees lead to gross and microscopic degenerative changes. They also noted that partial meniscectomies lead to less severe degenerative changes. They believed that there was a direct relationship between the degree of degenerative change and the amount of meniscus removed. McGinty et al reported early return to function with decreased morbidity and decreased complication rates after partial meniscectomy; this was compared to both open and arthroscopic techniques for total meniscectomy. Jackson and Dandy have documented improved results of partial meniscectomy when compared with total meniscectomy in an intermediate range (average 5 to 10 years) follow-up study. Earlier studies by the senior author, Hamberg et al, and Cassidy and Shaffer have documented that meniscal repairs can heal. The more recent follow-up study of DeHaven et al has documented that repaired menisci not only heal satisfactorily but that durability and biomechanical function can also be maintained. Of course, long-term review of these same patients will be necessary to prove that successful repair will prevent the degenerative changes noted in knees following meniscectomy.
In recent years, there has been a distinct trend toward a selective approach to the treatment of meniscus lesions. Partial meniscectomy, meniscus repair, and leaving certain tears alone have become alternatives to routine total meniscectomy. Once a meniscus tear is definitively diagnosed, the physician's first decision involves whether to treat the tear surgically or leave it alone. If surgical treatment is judged to be appropriate, the next decision concerns whether it should be repaired or partially excised. Total meniscectomy is reserved for tears for which any other option is unsuitable. The pertinent factors that should be considered in this decision-making process are: (1) the clinical evaluation, (2) associated lesions, and (3) the exact type, location, and extent of meniscus tear.
The treatment of patellofemoral pain is fraught with pitfalls; however, most of these pitfalls can be recognized. Results of LRR in appropriate circumstances are reasonably good, and the complications are acceptably low. Risk factors for poor results are identifiable, and avoidance of the common complications are necessary to achieve reliable results. Cases of persistent pain after LRR must be approached in a thorough and orderly fashion. There should be clear indications and cautious expectations for the success of subsequent procedures.
In a retrospective review of the results of 3,612 arthroscopic procedures that were performed for the treatment of an acute or a chronic meniscal lesion, with or without an associated ligamentous lesion, we identified eighty meniscal tears (in seventy-five patients) that had been assumed to be stable. Seventy were vertical longitudinal tears and ten were vertical radial tears. The seventy longitudinal tears included fifty-two lateral and eighteen medial meniscal lesions. All of the radial tears were in the lateral meniscus. Of the seventy-five patients, fifty-two had been followed for two to ten years. At the time of follow-up, only six of these fifty-two patients had needed additional intervention because of symptoms that were related to the meniscal tear. Four of them had the intervention after a sports-related traumatic extension of a stable tear, and two, because persistent symptoms were caused by the original meniscal lesion. A repeat arthroscopy was performed on thirty-two patients (twenty-six of whom had a longitudinal tear and six of whom had a radial tear), at an average of twenty-six months after the original arthroscopy. Seventeen of the twenty-six longitudinal tears had completely healed. Five of the six radial tears had no evidence of healing and one had extended. Neither ligamentous laxity nor a meniscal tear that was chronic at the time when it was discovered appeared to preclude healing of the stable longitudinal tears. No localized degenerative changes in the adjacent articular cartilage were found in association with any of the stable vertical longitudinal or radial meniscal lesions. Excluding the six patients who had had additional surgical treatment, none of the fifty-two patients who filled out a questionnaire reported that they had symptoms of a meniscal lesion, and none of the forty-two patients who were re-examined two years or more after the operation had signs of a meniscal lesion. Stable vertical longitudinal tears, which tend to occur in the peripheral vascular portions of the menisci, have great potential for healing. The tear should be left alone unless it is the only abnormality that is found and it is causing symptoms that warrant treatment. Stable radial tears, which tend to occur in the avascular inner one-third of the meniscus, have little potential for healing. Whether it is best to leave these lesions alone or to fashion an intact rim by contouring the meniscus was not established by this study.
Acute surgical treatment is generally recommended for patients in the high-risk category. The relative frequency of surgical compared with nonsurgical treatment in any individual practice setting depends on the patient population and can vary widely from one practice to another even though overall indications may be quite similar.
The ACL evaluation format is a modification and extension of Marshall's approach to evaluation of ligamentous injuries of the knee, whereby functional and clinical improvement can be analyzed independently as well as cumulatively. There are three major parts entered on separate forms: history and surgery (Form 1); initial evaluation and follow-up (Form 2); and complications (Form 3). Form 1 has five sections: patient information (demography); history of injury; previous surgery; surgery performed; and postoperative course. Form 2 has six sections. These are the Lysholm knee function scoring scale, Tegner activity level rating scale, physical findings, complications, supplementary data, and Tegner activity level definitions. Form 2 records the preoperative and follow-up assessments for up to a five-year follow-up period. Form 2 can be used independently of the other forms. Form 3 elaborates in a detailed manner a complication occurrence. The format provides the evaluator with an easy to use, "computer/user friendly," method for the comprehensive assessment of artificial or autologous anterior cruciate reconstruction of the knee. The authors advocate the use of the ACL format as an international standard for data storage to facilitate comparison of results with accuracy and uniformity among investigation centers.
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A selective approach to meniscus lesions has evolved to replace the traditional approach of total meniscectomy for all tears. The rationale is to preserve as much functional meniscus tissue as possible in the hope of decreasing the risk of late degenerative sequelae and still relieve the symptoms associated with the meniscus tear. The principles that should be considered for the various treatment options of leaving certain tears alone, meniscus repair, partial meniscectomy, and total meniscectomy have been reviewed. The early to intermediate results of this selective approach are encouraging and warrant continuation of its use. It should be emphasized, however, that continuing follow-up studies are necessary to establish whether the primary goal of improving long-term results following meniscus surgery will be achieved.
The rationale, surgical selection and technique, aftercare, and results of meniscus repair have been presented with special emphasis on the unique issues relating to the competitive athlete. Even though the risk of rerupture is higher in an athlete than a nonathlete (just as the risk of injury to a normal meniscus is higher), and in spite of the increased amount of time required for meniscus healing and maturation before return to athletics, repair of suitable meniscus tears should be considered for most, if not all, athletes.
The basic principles of arthroscopic meniscal surgery involve precise identification of the type, extent, and location of the lesion, followed by conceptualization of the steps required to resect the torn portion of the meniscus, then appropriate selection of portals and instrumentation to carry out the procedure. The standard two-puncture technique of anteromedial and anterolateral portals frequently needs to be supplemented by accessory portals. A combination of large and small mechanical instruments is necessary, and powered instrumentation is often helpful. Triangulation techniques are sufficient for handling the vast majority of meniscal lesions suitable for arthroscopic meniscal surgery.