Articular cartilage lesions in the symptomatic anterior cruciate ligament-deficient knee

Purpose: The goal of the study was to report the prevalence of the lesions of the articular cartilage of the femoral condyles and tibial plateau in patients with a symptomatic anterior cruciate ligament (ACL)-deficient knee undergoing day-case arthroscopy. Type of Study: Case series study. Methods: We studied 378 skeletally mature patients (average age, 27.3 years; range, 16–50 years; 282 men and 84 women), part of a sample of 1,978 patients undergoing a primary knee arthroscopy between January 1986 and August 1993. The articular cartilage lesions were classified according to Outerbridge by a single observer. We assessed the relationship between time of injury and articular cartilage lesions and between meniscal lesions and articular cartilage lesions. Results: A complete ACL tear was found in all 378 knees. Of these, 157 showed at least one lesion of the articular cartilage. The medial femoral condyle (MFC) showed the highest frequency of articular cartilage lesions, especially in the weight-bearing portion. Patients with a bucket-handle tear of the medial meniscus had greater degeneration of the MFC than those with other meniscal tears. A meniscal tear was associated with a greater degree of articular damage. The second most common lesion was a combined lesion of the medial and lateral compartments, followed by isolated lateral compartment lesion. A time-dependent pattern of development of articular cartilage lesions was identified. Conclusions: In patients with more advanced degenerative changes, the time from injury to arthroscopy was significantly longer than in patients with lesser articular surface abnormalities, and the presence of a meniscal tear was associated with a greater degree of articular cartilage damage. Patients with a symptomatic ACL-deficient knee and an associated tear of the medial meniscus are at high risk of having a lesion of the articular surface of the weight bearing area of the knee.     

Usefulness of knee arthroscopy for diagnosis of knee pain in pediatric patients: comparison with preoperative clinical diagnosis

Purpose

To investigate the knee arthroscopic findings of pediatric patients with knee pain.

Subjects

Ninety-five knees of 94 patients (46 males and 48 females) aged 15 years or younger who underwent knee arthroscopy during a 4-year period from January 2007 were studied. The mean age at surgery was 13.5 (7–15) years. The mean interval from symptom onset to arthroscopic examination was 6.8 months (5 days to 2 years 10 months).

Results

The most common cause of knee pain was sports-related activities (64 knees). Other causes included falling from a moving bicycle (5 knees), while knee pain appeared with no defined reason in 14 knees. The most frequent final diagnosis based on knee arthroscopic findings was anterior cruciate ligament (ACL) injury (35 knees), followed by discoid lateral meniscus (16 knees), lateral meniscal tear (11 knees), and medial plica syndrome (9 knees), while no arthroscopic abnormality was observed in 8 of 95 knees. Among the 95 knees, the diagnosis based on preoperative physical tests and imaging findings was different from the arthroscopic diagnosis in 16 knees, 8 of which were diagnosed preoperatively as medial meniscal tear.

Conclusion

ACL injury and discoid lateral meniscus were the predominant conditions in pediatric patients who underwent knee arthroscopic surgery for knee pain. Knee arthroscopy is useful to provide a definitive diagnosis for knee pain in pediatric patients. Preoperative evaluations had a diagnostic accuracy of only 83.2 % and failed to diagnose conditions such as medial plica syndrome and chondral injury. Therefore, diagnosis before knee arthroscopy has to be interpreted with caution.     

The posteromedial portal in knee arthroscopy: An analysis of diagnostic and surgical utility

We reviewed 400 consecutive knee arthroscopy cases in a predominantly sports medicine practice to determine (1) the frequency of posteromedial portal usage under a prospectively established set of indications, and (2) the impact of posteromedial portal access on patient diagnosis and management. Diagnostic posteromedial portals were used in 22% of anterior cruciate ligament (ACL)-deficient knees, and in 11% of stable knees with nonpatellar (usually meniscal) lesions. When used, posteromedial portal visualization showed treatable lesions 64% of the time, the majority of which were repairable peripheral meniscus tears. In 63% of these cases, no definite lesion had been identified by initial routine anterior portal viewing and probing. Of the 22 patients with posteromedial meniscus tears that were discovered only via posteromedial portal access, 9 had recently undergone anterior portal arthroscopy by other surgeons, during which none of these tears were detected. Posteromedial surgical portals (19 cases) were most useful for synovectomy, posterior cruciate stump resection before arthroscopic reconstruction, and posterior horn medial meniscectomy in exceptionally tight knees. Posteromedial portal access is often useful diagnostically in cases where (1) posteromedial meniscal lesions are frequent (i.e., ACL-deficient knees) and/or suspected on the basis of preoperative symptoms or imaging studies, and (2) full, direct visualization of the entire superior meniscosynovial junction is not possible via standard anterior portals. The option of a surgical posteromedial portal should be entertained whenever frontal approaches for posteromedial instrument work prove inefficient or unsuccessful.     

Meniscal tearing after ACL reconstruction

The knees of 72 patients with unilateral anterior-cruciate- ligament (ACL) injury were analyzed before ACL reconstruction as well as by follow-up arthroscopy on the day of staple removal. At ACL reconstruction 31 lateral menisci and 40 medial menisci were found to be normal. 28 lateral menisci and 24 medial menisci were treated surgically, while 13 lateral menisci and 8 medial menisci with small or incomplete meniscal tearing were not treated. At follow-up arthroscopy there were 3 new cases of lateral meniscal tearing and 3 new cases of medial meniscal tearing in the groups diagnosed as normal prior to surgery. Two of the 13 cases with small or incomplete lateral meniscal tearing required resection, 8 healed and the other 3 demonstrated no progressive change. Four of the 8 cases with small or incomplete medial meniscal tears healed, 3 exhibited no progressive change and one required surgical treatment. There was no correlation between meniscal tearing and knee instability as indicated by a positive Lachman test or a positive pivot shift sign. The results of the present study indicate that ACL reconstruction prevents progressive changes in meniscal tears and will prevent secondary osteoarthritis, and that some small tears of the lateral meniscus require no surgical treatment.     

A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears

A prospective and retrospective study was undertaken to compare the accuracy of magnetic resonance imaging (MRI) with clinical examination in diagnosing meniscal and anterior cruciate ligament (ACL) tears. Pathological findings were then confirmed during arthroscopy. One hundred fifty-four patients clinically diagnosed with a meniscal or ACL tear who ultimately had arthroscopic knee surgery were evaluated; 100 patients underwent clinical examination followed by MRI, and 54 underwent clinical examination alone. The presence or absence of meniscal and ACL tears was confirmed during arthroscopy. The accuracies of clinical examination and MRI were compared for the 100 patients who underwent both clinical examination and MRI. The accuracy of MRI was 75% for medial meniscal tears, 69% for lateral meniscal tears and 98% for ACL tears. The accuracy of clinical examination was 82% for medial meniscal tears, 76% for lateral meniscal tears and 99% for complete tears of the ACL. Furthermore, the accuracy of clinical examination for the 54 patients who underwent clinical examination alone was not significantly different from the accuracy of clinical examination in the 100 patients who also underwent MRI. There was no significant difference between the accuracy of clinical examination and MRI in the diagnosis of meniscal and ACL tears and, overall, MRI contributed to treatment in only 16 of 100 cases. Based on these findings, we feel that MRI, except in certain circumstances, is an expensive and unnecessary diagnostic test in patients with suspected meniscal and ACL pathology.     

Diagnostic value of clinical tests and Mri for meniscal injury in patients with anterior cruciate ligament injury: Case series study

Introduction and importanceMeniscal tear is one of the most common knee injuries and knee surgery procedures. It is frequently associated with an anterior cruciate ligament (ACL) injury. We conducted this study, on patients with ACL reconstruction surgeries, which were occasionally accompanied by meniscal tears, in order to determine the diagnostic value of clinical examinations for meniscal tear, both individually and in combination, in correlations to magnetic resonance imaging (MRI) scans, with the goal of improving clinical diagnosis for patients with meniscal injuries in particular, as well as meniscal injuries associated with cruciate ligament knee injuries.Case presentation50 patients were thoroughly clinically examined, using Joint line tenderness, Thessaly test, McMurray's test, Apley's test followed by MRI, before their scheduled ACL reconstruction arthroscopic surgeries. The meniscal tears were then identified during the procedure, and were treated, if necessary. The data before and after the surgery was taken into calculating, with arthroscopic findings serving as the gold standard. Results: the sensitivity, specificity and accuracy of each clinical tests and MRI scans respectively were: for medial meniscus, Joint line tenderness (70%; 53,3%; 60%); McMurray's test (80%; 73,3%: 76%); Apley's test (65%; 70%; 68%); Thessaly test(70%; 76,7%; 74%); MRI (90%; 83,3%; 86%); lateral meniscus: Joint line tenderness (73%; 66,7%; 70%); McMurray's test (69,2%; 75%: 72%); Apley's test (69,2%; 70,8%; 70%); Thessaly test (73,1%; 75%; 74%); MRI (88,5%; 87,5%; 88%). However, when combining at least two positive tests into a single composite test, the diagnostic value is considerably enhanced with sensitivity, specificity and accuracy of 85%, 73,3%, 78% for medial meniscus, 92,3%, 87,5%, 90% for lateral meniscus.Clinical discussionClinical tests are essential for diagnosis of meniscal tears, although inconsistent. A composite test consisting of at least two positive tests can considerably enhance the diagnostic value, even comparable to MRI scans. However, after the clinical examination, MRI is still necessary for the diagnostic process of meniscal injuries in particular, as well as meniscal injuries associated with cruciate ligament knee injuries.ConclusionThe combination of clinical tests and MRI images will give a precise diagnosis as well as surgical indication for meniscus injury in patients with anterior cruciate ligament tear.     

Meniscal lesions in so-called "isolated" ruptures of the anterior cruciate ligament. Apropos of 59 cases

Between December 1984 and March 1987, i.e. a period of 27 months, the authors operated on 59 "isolated" fresh ruptures of the ACL with routine evaluation of the posterior horns of the medial and lateral menisci. Lesions were investigated either by arthroscopy (23 cases) or by anterior arthrotomy with routine medial and lateral retro-ligamentous counter-incision (36 cases). This revealed 21 lesions of the medial meniscus (i.e. 35.5%) and 38 lesions of the lateral meniscus (i.e. 64.5%). Lesions of both menisci were present in 16 knees (27%) and only 16 knees (27%) were found to be free of any meniscal lesion. The majority of meniscal lesions were viable and could be sutured in 86% of cases for the medial meniscus and 87% of cases for the lateral meniscus. From the standpoint of operative technique, posterior lesions are relatively poorly visualized by arthroscopy (notably concerning the posterior horn of the medial meniscus though it is easier to assess the stability of the meniscus by this technique using the palpating hook. Lesions are well visualized by medial and lateral retroligamentous counter-incisions, but it is difficult to assess meniscus stability. Finally it should be noted that all of these ruptures of the ACL were dealt with by reconstruction of the central pivot either by suture and a strengthening procedure (semitendinous) or by ligament plasty from the outset.     

The relationship between intra-articular meniscal,chondral, and ACL lesions: finding from 1,774 knee arthroscopy patients and evaluation by gender

Knowing the relationship between diagnoses is important in knee arthroscopy in terms of defining possible treatment modalities preoperatively. The purpose of our study was to define the diagnoses made intraoperatively through knee arthroscopy and the relationships between them. We evaluated the results of knee arthroscopies performed over a 10-year period. The sites and sizes of chondral lesions, the existence of anterior cruciate ligament (ACL) injury, and the sites of meniscal lesions were noted for a total of 1,774 patients. The relationships between these lesions were evaluated statistically. Chondral lesions and posterior medial meniscal tears were predominant in females, whereas complete ACL tears were predominant in males. ACL tears were commonly accompanied by medial and lateral meniscal bucket-handle tears. In cases with advanced chondral lesions, medial and lateral posterior meniscal and lateral anterior meniscal tears were more common. According to our results, posterior tears of the medial menisci, medial and lateral femoral condyles, lateral tibial plateau type 3 or 4 cartilage lesions, and the rate of diagnostic arthroscopy were higher in females, while middle substance and bucket-handle tears of medial menisci and total rupture of the ACL were more common in males. ACL injuries were seen to coexist with medial or lateral menisci bucket-handle tears, with no relationship between the site or size of the chondral lesions. A relationship between medial and lateral meniscal tears and the site of femoral and tibial chondral surface lesions was detected.     

The Results of All-Inside Meniscus Repair Using the Viper Repair System Simultaneously with Anterior Cruciate Ligament Reconstruction

Background

Meniscus tears are commonly associated with anterior cruciate ligament (ACL) ruptures. It is essential to repair meniscal tears as much as possible to prevent early osteoarthritis and to gain additional stability in the knee joint. We evaluated the results of arthroscopic all-inside repair using the Meniscal Viper Repair System (Arthrex) on meniscus tears simultaneously with ACL reconstruction.

Methods

Nineteen out of 22 patients who were treated with arthroscopic all-inside repair using the Meniscal Viper Repair System for meniscus tear associated with ACL rupture were evaluated. ACL reconstructions were performed at the same period. The mean follow-up period was 16.5 months (range, 12 to 24 months). The clinical results of the meniscus repair were evaluated by symptoms (such as catching or locking), tenderness, effusion, range of motion limitation, and the McMurray test. Clinical success was defined by negative results in all five categories. The Hospital for Special Surgery (HSS) score was evaluated. Objective results were evaluated with secondary look arthroscopy or magnetic resonance imaging (MRI). The MRI results were categorized as completely repaired, incompletely repaired, and failure by Henning''s classification. The results of second-look arthroscopy were evaluated with the criteria of meniscal healing.

Results

The clinical success rate was 95.4% and the HSS scores were 93.9 ± 5.4 at the final follow-up. According to Henning''s classification, 15 out of 18 cases showed complete healing (83.3%) and two cases (11.1%) showed incomplete healing. Seventeen out of 18 cases that underwent second-look arthroscopy showed complete healing (94.4%) according to the criteria of meniscal healing. Only one case showed failure and the failure was due to a re-rupture at the sutured area. Complications of ACL reconstruction or meniscus repair were not present.

Conclusions

The results demonstrate that arthroscopic all-inside repair using the Meniscal Viper Repair System is an effective treatment method when it is performed simultaneously with ACL reconstruction.     

Arthroscopic treatment of cysts of the menisci. A preliminary report

A retrospective clinical study evaluated the results of arthroscopic management of cysts of the menisci. From 1979 to 1984, 24 patients with a diagnosis of meniscal cysts associated with tears of the semilunar cartilage were treated with partial meniscectomy and cyst decompression. The mean age was 29.9 years (range, 14-52 years). Each patient had tenderness over the joint line with a palpable mass. There were 25 cases of meniscal cysts, with one patient having a bilateral cyst. Twenty-two cysts involved the lateral meniscus, and three cysts were on the medial side of the knee. The follow-up period ranged from 16 to 48 months (mean, 33.5 months). All patients had a meniscal tear; most tears were either horizontal or transverse, with or without flap formation. The pathology was in the middle or anterior one-third of the meniscus. The arthroscopic surgery consisted of partial excision of the meniscal tear, leaving a peripheral rim at times, coupled with aspiration of the cyst material or manipulation of its contents into the joint cavity. No cyst recurred, and in every patient except one, preoperative symptoms disappeared. All patients but one were satisfied with the results. Two patients had a second arthroscopy, and no evidence of instability of the peripheral rim was found.     

Anterior cruciate ligament tears in skeletally immature patients: meniscal pathology at presentation and after attempted conservative treatment.

We evaluated 12 skeletally immature patients with acute, intrasubstance tears of the anterior cruciate ligament (ACL) and open physes for meniscal pathology. Arthrograms were completed in 10 of 12 patients, and subsequent arthroscopy confirmed 8 meniscal tears (4 medial, 4 lateral) in 6 patients. Four patients with repairable menisci underwent arthroscopic meniscal repair and stabilization. Eight patients received quadriceps and hamstrings rehabilitation and returned to sports with a brace. After return to sports, all braced patients developed instability with multiple episodes of "giving way." Average time from initial injury to first episode of instability was 7 months. Seven patients sustained further meniscal damage an average of 15 months (range 7-27 months) after initial injury. We conclude that meniscal pathology is commonly associated with ACL tears in skeletally immature patients and we recommend arthrography or arthroscopy to evaluate patients with suspected ACL tears. Brace management did not prevent instability or new meniscal tears.     

Associated injuries in pediatric and adolescent anterior cruciate ligament tears: Does a delay in treatment increase the risk of meniscal tear?

Purpose: To evaluate the incidence of associated injuries and meniscal tears in children and adolescents with anterior cruciate ligament (ACL) tears, we performed a retrospective review of patients, age 14 and younger, who were treated surgically at our institution. Type of Study: Retrospective review. Methods: We reviewed 39 patients (30 girls, 9 boys) with an average age of 13.6 years (range, 10 to 14 years) who underwent surgical treatment of the ACL; 24 right knees and 15 left knees were treated. Of the injuries treated, 24 occurred by a twisting mechanism, 10 were the result of contact, and 5 occurred from hyperextension. Thirty-five injuries occurred during sports activities, and 2 were sustained in motor vehicle accidents. The mean duration from injury to operative treatment was 101 days (range, 7 to 696 days). Injuries were classified as acute (n = 17) if surgery was performed within 6 weeks of injury and chronic (n = 22) if surgery was performed after 6 weeks from injury. Relationships between medial and lateral meniscal injuries and the time from injury to surgery were analyzed, and the 2 groups, acute and chronic, were compared. Finally, the patterns of meniscal injury were compared. Results: Twenty-six patients had associated injuries (10 medial meniscal tears, 15 lateral meniscal tears, 3 medial collateral ligament tears, and 1 fractured femur). The association between medial meniscal tears and time from injury to surgery was highly statistically significant (P = .0223). There was no statistical significance between the incidence of lateral meniscal tears and time. Medial meniscal tears were more common in the chronic group (36%) than in the acute group (11%), whereas lateral meniscal tears were found with equal frequency. Medial meniscal tears that required surgical treatment (either partial excision or repair) were more common in the chronic group, and lateral meniscal tear patterns were equally distributed. Conclusions: Evidence from this study supports the contention that associated injuries are common in young individuals with ACL tears. Furthermore, the data also show that a delay in surgical treatment was associated with a higher incidence of medial meniscal tears.     

Diagnostics of degenerative meniscal tears at 3-Tesla MRI compared to arthroscopy as reference standard

Introduction The goal of this study was to evaluate the diagnostic performance of 3-Tesla MRI for the assessment of degenerative meniscal tears in clinical practice. Materials and methods In patients with chronic knee pain, a negative history of acute trauma and a mean age of 52 years, 3-Tesla MRI were performed a few days prior to arthroscopy. In 86 menisci, diagnostic values of 3-Tesla MRI for the detection of degenerative tears were evaluated using arthroscopy as reference standard. The MRI classification, for meniscus diagnostics, described by Crues was used. Results At arthroscopy, all tears identified (19 horizontal, 7 complex, 3 radial) were degenerative as confirmed by histological examination. MRI grade II lesions had a prevalence of 24% and a rate of 24% of missed tears, whereas grade I lesions were not associated with a torn meniscus at arthroscopy. For meniscal tears, (grade III) sensitivity and specificity of 3-Telsa MRI was 79 and 95% for both menisci, 86 and 100% for the medial meniscus, and 57 and 92% for the lateral meniscus. The best diagnostic performance was found for complex tears, horizontal tears showed relatively good results, poor results were documented for radial tears. Conclusion For the medial meniscus, where horizontal and complex tears were more prevalent, 3-Tesla MRI shows a higher accuracy than for the lateral meniscus. Particularly with regard to the medial meniscus, 3-Tesla MRI could be effectively used when a degenerative tear is suspected. Nevertheless, in regard to a remarkable number of false positive and false negative findings the diagnostic value of a 3-Tesla MRI investigation should not be overestimated.     

The utility of clinical examination in the diagnosis of medial meniscus injury in comparison with arthroscopic findings

A prospective study was conducted to evaluate the utility of clinical meniscal tests (joint line tenderness, McMurray test, Apley test and Steinmann I sign) in the diagnosis of medial meniscus injury. The sensitivity, specificity and diagnostic accuracy of these tests were calculated in comparison with arthroscopic findings in 50 patients presented to us between January 2005 and January 2006 with knee pain and clinical manifestations of meniscal injury. The arthroscopy revealed that 32 patients (30 males and 2 females, aged 19–39 with mean of 27 years) had medial meniscus injury. Joint line tenderness showed the best diagnostic accuracy (80%) while Steinmann I sign had promising diagnostic characteristics. Similar to previous reports, the present study confirmed that caution should be used when interpreting the McMurray and Apley tests in the diagnosis of medial meniscus injury.     

Die arthroskopische Meniskusrefixation mit einem All-inside-Nahtsystem

OBJECTIVE: Application of an arthroscopic suture system to restore the form and function of the meniscus by adaptation of a longitudinal tear close to the base. INDICATIONS: Unstable longitudinal tears near the base of the meniscus, mainly in the posterior horn of the medial or lateral of the meniscus. Dislocated bucket-handle tears of the medial and lateral meniscus close to the base. CONTRAINDICATIONS: Poor tissue quality with fibrillated meniscal tissue. Meniscal tears in the avascular zone (zone I). Insufficient blood supply from the joint capsule and the base of the meniscus. Degenerative meniscal lesions. Anterior or posterior knee joint instability. Allergic reactions to nonresorbable suture material. SURGICAL TECHNIQUE: Standard anterior arthroscopic portals. Arthroscopic assessment of the meniscal tear using the probe. Revitalization of the tear margins and perforation of the meniscal base to induce bleeding. Adaptation of the tear margins and fixation with a suture-anchor system using an ipsilateral standard portal for tears in the posterior horn or by way of a contralateral standard portal for tears in the lateral horn. POSTOPERATIVE MANAGEMENT: Full weight bearing with the knee in extension in a knee immobilizer, relative to the pain threshold in the 1st postoperative week. Range of motion exercises without weight bearing from full extension to 90 degrees knee flexion (0/0/90). If simultaneous reconstruction of the anterior cruciate ligament (ACL) is being performed, rehabilitation protocols follow the principles for ACL reconstruction. RESULTS: Since the year 2000, meniscal tears in more than 300 patients have been repaired with the all-inside suture system. In the context of a multicenter study by ESSKA (European Society for Sports Medicine, Surgery and Arthroscopy) involving 20 patients, the result was evaluated by direct MRI arthrography (gadolinium). The suture bar anchors were generally not detectable, the incision channels produced a hypodense signal in the meniscus tissue. If re-rupture occurred, it was because the meniscus had pulled out of the suture loop. Cartilaginous lesions were not found. There were no complications related to the nonresorbable suture bar anchors.     

Anomalous insertion of the medial menisci

Many types of meniscal anomalies have been reported. The authors encountered two cases of anomalous insertion of the anterior horn of the medial menisci to the lateral femoral condyle, which ran up along the course of the anterior cruciate ligament (ACL), but was independent of the ACL. These anomalies were noted during arthroscopic examination and surgery of the ipsilateral knee for a torn discoid meniscus and a patellar fracture. A 34-year-old woman had a horizontal tear of the lateral discoid meniscus. We performed arthroscopic partial meniscectomy of the inner torn portion of the lateral discoid meniscus and contoured it to resemble a normal meniscus. An anomalous insertion of the medial meniscus was found on examination of the joint during surgery. A 32-year-old man had a patellar fracture and we performed reduction under arthroscopy and internal fixation with cannulated screws. The same anomalous insertion of the medial meniscus was also found on examination of the joint during surgery. We report the cases with a review of the literature.Arthroscopy 1998 Jul-Aug;14(5):505-7     

Editorial Commentary: Arthroscopy Is the Gold Standard for Diagnosis of Meniscal Ramp Lesions: Magnetic Resonance Imaging Also May Be Helpful

Identifying and treating medial meniscal ramp lesions in conjunction with ligament reconstruction restores critical stability in knees with ligament injuries. This must begin with obtaining high-quality magnetic resonance imaging (MRI) and critical evaluation of the MRI and include a subsequent thorough arthroscopic examination of these knees. As evident in previous studies, most surgeons associate medial meniscal ramp lesions with anterior cruciate ligament (ACL) tears. Biomechanical studies have reported that a ramp lesion produces significant anterior tibial translation and external rotational instability in ACL-deficient knees that is not reestablished with an isolated ACL reconstruction. In addition, recent research identified ramp lesions in one-third of multiligament knee injuries with an intact ACL and two-thirds of patients with posteromedial tibial plateau bone bruises on MRI. Restoring knee stability and biomechanics is necessary in treating all knee ligament injuries. Don’t miss the meniscal ramp lesion. Have a high index of suspicion, obtain a high-quality MRI,and arthroscopically evaluate the meniscocapsular junction of the medial meniscus, especially if there is a bone bruise seen on MRI.     

Osteonecrosis of the knee after arthroscopic surgery for meniscal tears and chondral lesions.

PURPOSE: Avascular necrosis of the knee following arthroscopic surgery has been described. The purpose of this article is to report a large series of patients who developed avascular necrosis after arthroscopy of the knee in an effort to delineate casual factors and results of treatment. TYPE OF STUDY: Case series. METHODS AND MATERIALS: The charts, radiographs, and magnetic resonance imaging (MRI) scans of patients who developed osteonecrosis (ON) of the knee after routine arthroscopic surgery were reviewed. Only those patients with no evidence of ON on preoperative MRI performed 6 weeks or longer after symptom onset and who postoperatively developed ON confirmed by repeat MRI and/or by pathological testing (specimens obtained at subsequent total knee arthroplasty) were included in the study. Seven patients with average age of 60 years (range, 41 to 79 years) met these inclusion criteria. RESULTS: The lesions noted at arthroscopy included 4 medial meniscus tears, 3 lateral meniscal tears, 6 chondromalacia of the medial femoral condyle, 2 chondromalacia of the medial tibial plateau, 1 chondromalacia of the lateral femoral condyle, 1 chondromalacia of the lateral tibial plateau, and 2 chondromalacia of the patella. The location of postarthroscopy ON correlated geographically with pre-existing pathology. All 7 patients had meniscal and/or chondral lesions addressed surgically in the compartment that subsequently developed ON. Six of the 7 patients had an adjacent ipsilateral meniscus tear treated with partial meniscectomy (4 medial, 2 lateral). In addition, of the 4 patients who developed ON of the medial femoral condyle, all had overlying chondromalacia, 3 of whom were treated with arthroscopic chondroplasty. Of the 2 patients with lateral meniscal tears, 1 developed ON of the lateral femoral condyle and the other developed ON of the lateral tibial plateau. Three patients went on to require total knee arthroplasty, and 2 high tibial osteotomy. One patient's ON resolved and another patient was lost to follow-up. CONCLUSION: ON should be considered in patients who have worsening symptoms after arthroscopy of the knee. These findings suggest a possible relationship between arthroscopic treatment of chondral and meniscal lesions and later appearance of ON in some patients. The role of arthroscopy in the development of ON needs to be further studied. Those at risk are elderly patients with chondral and meniscus lesions.     

Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears

BACKGROUND: Clinical tests used for the detection of meniscal tears in the knee do not present acceptable diagnostic sensitivity and specificity values. Diagnostic accuracy is improved by arthroscopic evaluation or magnetic resonance imaging studies. The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination test for the detection of meniscal tears. METHODS: Two hundred and thirteen symptomatic patients with knee injuries who were examined clinically, had magnetic resonance imaging studies performed, and underwent arthroscopic surgery and 197 asymptomatic volunteers who were examined clinically and had magnetic resonance imaging studies done of their normal knees were included in this study. For clinical examination, the medial and lateral joint-line tenderness test, the McMurray test, the Apley compression and distraction test, the Thessaly test at 5 degrees of knee flexion, and the Thessaly test at 20 degrees of knee flexion were used. For all clinical tests, the sensitivity, specificity, false-positive, false-negative, and diagnostic accuracy rates were calculated and compared with the arthroscopic and magnetic resonance imaging data for the test subjects and the magnetic resonance imaging data for the control population. RESULTS: The Thessaly test at 20 degrees of knee flexion had a high diagnostic accuracy rate of 94% in the detection of tears of the medial meniscus and 96% in the detection of tears of the lateral meniscus, and it had a low rate of false-positive and false-negative recordings. Other traditional clinical examination tests, with the exception of joint-line tenderness, which presented a diagnostic accuracy rate of 89% in the detection of lateral meniscal tears, showed inferior rates. CONCLUSIONS: The Thessaly test at 20 degrees of knee flexion can be used effectively as a first-line clinical screening test for meniscal tears, reducing the need for and the cost of modern magnetic resonance imaging methods.