膝关节碘水造影对半月板损伤的诊断价值

目的和方法:本文回顾分析1992年2月～1994年4月,41例半月板损伤患者的膝关节造影结果并与关节镜做对比。结果:膝关节造影对内侧半月板准确率85.4％,外侧半月板准确率65.9％。结论:膝关节造影对内侧半月板损伤能提供精确的诊断,其准确率可接近MRI。     

Comparison of clinical examination with NMR spectroscopy in the diagnosis of meniscal lesions in daily practice]

INTRODUCTION: We investigated the value of Magnetic Resonance Imaging compared to the clinical examination for meniscal lesions. MATERIAL AND METHODS: From 1991 to 1995 we did arthroscopic evaluation at 824 patients with the diagnose "meniscal lesion". 73 of them had an MRI-examination elsewhere before surgery. RESULTS: During arthroscopy we found 473 lesions of the medial meniscus and 160 of the lateral meniscus. The MRI-examination had an accuracy of 70% for the medial meniscus (sensitivity 79%, specificity 63%, positive predictive value 64%, negative predictive value 78%) and 78% for the lateral meniscus (sensitivity 50%, specificity 86%, positive predictive value 50%, negative predictive value 86%). The clinical examination had an accuracy of 73% for the medial meniscus (sensitivity 98%, specificity 39%, positive predictive value 69%, negative predictive value 88%) and 87% for the lateral meniscus (sensitivity 67%, specificity 92%, positive predictive value 65%, negative predictive value 93%). CONCLUSIONS: We conclude, that by an experienced examiner a meniscal lesion can be diagnosed adequately by clinical examination alone. The different radiologists who did the MRI examination in our study belong to different outward departments and used different apparatus with sometimes insufficient quality of the pictures. Therefore the sensitivity and specificity of the MRI for meniscal lesions is markedly lower than in other studies of departments where a close cooperation between the radiologist and the orthopedic surgeon is performed.     

Correlation between clinical, arthrographic and arthroscopic findings in meniscal lesions

There are many different references about the accuracy of physical examination and arthrographic exploration in diagnosing meniscal tears. Therefore we analysed retrospectively 334 arthroscopic examinations, which were done because of a suspected or a proven meniscal lesion. We found an accuracy of 84% true-positives and true-negatives with regard to the physical examination and an accuracy of only 71.2% with regard to the arthrographic investigation. Our results were converted into a formula (stated in [11]), declaring the predictive value of a result. These findings led us to a certain scheme in diagnosing meniscal or other knee pain, presented here.     

Precision in the diagnosis of meniscal lesions: a comparison of clinical evaluation, arthrography, and arthroscopy

We assessed the accuracy of clinical evaluation, arthrography, and arthroscopy in the diagnosis of meniscal lesions in fifty knees in which arthrotomy was performed for disabling symptoms after evaluation by these three methods. At surgery, forty-seven menisci were removed, of which forty-four were abnormal and three were normal. In three patients with normal menisci, loose bodies were found in two and the exploration was negative in one. In the forty-four knees with a meniscal lesion, a correct diagnosis was made clinically forty time, arthrographically thirty-nine times, and arthroscopically thirty-two times. Most errors occurred in the knees with posterior horn lesions of the medial meniscus. Clinical diagnosis was least accurate for lesions of the lateral meniscus (four missed) and arthroscopy was least accurate for lesions of the posterior horn of the medial meniscus (ten missed). Arthrography appeared to provide collateral evidence of lesions not seen directly. Based on this study it was concluded that even with negative findings by arthroscopy and arthrography it still may be necessary occasionally to remove a meniscus on the basis of the clinical evaluation.     

关节镜下同种异体半月板移植的疗效分析

目的 探讨关节镜下同种异体半月板移植微创手术的临床疗效.方法 2006年1月至2008年7月,对21例(22侧)半月板损伤后切除半月板的患者行关节镜下同种异体半月板移植手术.在关节镜下用膝关节定位器制作容纳半月板前、后角骨栓(骨桥)的骨道(骨槽),将大小匹配的带有前、后角骨栓(骨桥)的同种异体半月板植入适当位置,并与关节囊缝合固定.全部患者于术前行MR检查,13例于术后1年复查MR.采用VAS疼痛评分、Lysholm评分和IKDC分级方法评价膝关节功能.3例分别于术后3、9及18个月行二次关节镜探奁.结果 全部病例无手术副损伤、感染或需摘除移植半月板者.随访6～28个月,平均16.3个月.患者手术前后膝关节均可伸直,屈曲活动度差异无统计学意义.VAS疼痛评分术前(7.0±2.3)分、术后(3.2±1.3)分,Lysholm评分术前(64.3±15.7)分、术后(80.1±19.4)分,差异均有统计学意义.术后IKDC分级较术前明显改善.术后3个月关节镜检查示移植半月板与关节囊基本愈合,形态完整;术后9个月移植半月板质地偏硬;术后18个月移植半月板与关节囊愈合牢固,质地接近正常半月板.术前与术后关节软骨分级差异无统计学意义.结论 同种异体半月板移植早期临床效果满意,移植半月板与周围组织愈合良好.但术后早期稳定性稍差,容易损伤.     

The arthroscopic anatomy of symptomatic meniscal lesions

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.     

Double contrast arthrography of the knee. A comparison to clinical diagnosis and arthroscopic findings

The accuracy of pre-arthroscopic double contrast arthrography was evaluated in 100 consecutive patients. Meniscal tears were correctly diagnosed arthrographically in 76% of cases, and clinically in 85% of cases. Although reasonably accurate in determining the location of the meniscal tear, arthrography was significantly inaccurate in the evaluation of the type of tear. The status of the anterior cruciate ligament was correctly interpreted by arthrogram in 76% of cases; the integrity of the ligament was correctly assessed in 94% of cases by clinical examination without anesthesia. It appears, therefore, when compared to initial clinical examination, double contrast arthrography is of limited usefulness as a pre-surgical aid to the diagnosis of intra-articular knee pathology.     

Kinematics in the diagnosis of meniscal lesions

We have studied the findings at operation of 336 knees with a preoperative diagnosis of a meniscus lesion.In 146 knees operated on by three surgeons, after a detailed history and clinical assessment, the findings confirmed the preoperative diagnosis in 116 knees (79.5 per cent). In 47 knees operated on after double contrast arthrography, the diagnosis was confirmed in 43 knees (91.5 per cent). In 50 knees operated on after a study of the instant centre of pathway, the diagnosis was confirmed in 45 knees (90 per cent).We found an improvement of preoperative diagnosis of up to 95.5 per cent when the combination of instant centre of pathway and arthrography were positive in 89 out of 93 knees.     

膝关节镜Clearfix与FasT-Fix半月板修复系统修复半月板损伤的比较

目的比较膝关节镜Clearfix与FasT—Fix半月板修复系统修复半月板损伤的临床愈合率。方法1998年11月-2001年6月，膝关节镜下采用Clearfix系统修复半月板损伤50例；2001年6月～2002年12月，关节镜下采用FasT—Fix系统修复半月板损伤61例。比较2组半月板损伤的临床愈合率。判断半月板损伤临床愈合的标准包括关节无交锁、无肿胀、关节间隙无压痛以及McMurray试验阴性。结果Clearfix组平均随访19个月（12—48个月），根据临床标准12例半月板修复术失败，临床愈合率为75．O％（36／48）；FasT—Fix组平均随访18个月（14—28个月），5例半月板修复术失败，临床愈合率为91．4％（53／58）。Fast-Fix组半月板临床愈合率显著高于Clearfix组（Z=-2．277，P=0．023）。结论与Clearfix系统相比，FasT—Fix系统修复半月板损伤可获得较高的临床愈合率。     

全关节镜下应用FasT—Fix修复半月板损伤的中期疗效观察

目的探讨关节镜下应用FasT-Fix缝合修复半月板损伤,并在有效的康复治疗后评价其中期临床疗效。方法回顾性研究因半月板损伤而在关节镜下采用FasT—Fix缝合修复治疗的患者。本组患者24例（男14例,女10例）,共计31例半月板损伤,年龄15—52岁（平均28．3岁）。其中12例是单纯的半月板修复缝合、19例患者是在前交叉韧带重建术后进行的缝合。包括内侧半月板损伤12例,外侧半月板损伤9例,内外侧半月板同时损伤5例,病程1周-23周（除去2例3年的患者）,平均12周。撕裂长度平均15mm（10～25ram）。其中红红区15例,红白区16例,没有白白区进行缝合。平均缝合针数2针（1～4针）。结果所有病例术后均无并发症的发生,随访时间2—4年,平均为2．7年,Lysholm,Tegner,IKDC评分术前、术后评分分别为：45．3、85．4;2．1、3．5;3．1、7．1,差异有统计学意义（P〈0．01）。结论FasT-Fix修复半月板损伤患者在有效康复下,通过中期随访获得88％的优良率。     

关节镜下半月板缝合术治疗中年人半月板损伤的疗效评估

目的:观察关节镜下半月板缝合术治疗中年人半月板损伤的临床疗效及愈合情况。方法 :自2014年3月至2015年1月,对40例符合纳入标准的中年膝关节半月板损伤患者采用关节镜下半月板缝合术进行治疗,男24例,女16例;平均年龄(52.65±3.63)岁(50~60岁);左膝28例,右膝12例;屈曲角(117.50±7.16)°(110°~130°)。术前膝关节Lysholm评分54.30±14.72(23~71分),IKDC评分50.65±15.95(18~78分),WOMAC评分23.80±19.39(2~75分)。均采用关节镜下全关节内半月板缝合术,术后以临床评分及MRI检查来评估疗效。结果:所有手术成功,未见严重并发症。术后随访6~12个月,无失访病例。所有患者保持5级肌力,膝关节活动度正常,能完全伸直及完全屈曲。40例平均屈曲角(125.00±5.13)°(110°~130°),较术前改善(t=-3.47,P=0.003)。终末随访膝关节Lysholm、IKDC及WOMAC评分分别为79.50±8.70(t=-7.790,P=0.000),79.40±10.40(t=-8.431,P=0.000),8.15±6.77(t=3.988,P=0.001),均较术前改善。MRI随访完全愈合4例,部分愈合22例,未愈合14例。损伤较小缝合3针及以下者,不愈合率为27.3%(6/22);损伤较大缝合大于3针者,不愈合率为44.4%(8/18)。结论:关节镜下半月板缝合术治疗中年人单纯半月板损伤疗效良好。术后不愈合率达35%,中年人半月板愈合能力较差。损伤较小者愈合率相对较高,损伤越大愈合率越低。     

Positive contrast arthrography in the diagnosis of ligament lesions in the upper ankle joint]

There are a great number of open questions in the diagnosis and the management of ligament lesions of the ankle joint. On the basis of the data of the literature and the author's experiences the advantages of the contrast arthrography of the ankle-joint may be resumed in the following: 1. No narcosis is necessary. 2. More exact determination of the site of the lesion is possible. 3. Therefore proper treatment may be chosen. 4. The incidental technical errors are more easily to be verified. (Paraarticular administration of the contrast medium is immediately demonstrable, whereas faulty observance of the prescriprions becomes not always evident from the roentgenogram). 5. No comparative roentgenograms are necessary. 6. The X-ray staff is not exposed to X-ray radiation.     

Reliability of clinical diagnosis in meniscal tears

This retrospective study was conducted to analyse the reliability of clinical diagnosis in meniscal tear injuries. All patients attending our clinic with knee pain from January 2003 to December 2004 underwent systematic and thorough clinical assessment. One hundred and fifty patients were clinically diagnosed to have meniscal tears. All these patients underwent therapeutic arthroscopic knee surgery. The clinical diagnosis was confirmed during this procedure. The accuracy, sensitivity and specificity were calculated based on these arthroscopic findings. The accuracy of clinical diagnosis in our study was 88% for medial meniscal tears and 92% for lateral meniscal tears. The results of this study demonstrate that clinical diagnosis of meniscal tears is as reliable as the results published by other authors for magnetic resonance imaging (MRI) scan. We recommend the use of MRI for more doubtful, difficult and complex knee injuries.

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Résumé Cette étude rétrospective analyse la fiabilité du diagnostic clinique dans les lésions méniscales. De janvier 2003 à décembre 2004 tous les patients présentant des gonalgies ont eu un examen clinique minutieux. 150 avaient des signes de déchirure méniscale et ils ont eu une arthroscopie thérapeutique qui a permis de calculer l’exactitude, la sensibilité et la spécificité du diagnostic. L’exactitude était de 88% pour les lésions méniscales médiales et de 92% pour les lésions latérales. Les résultats montrent que le diagnostic clinique était aussi fiable que le diagnostic par IRM d’après des résultats publiés par d’autres auteurs.

     

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.     

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.     

Clinical results of arthroscopic all-inside lateral meniscal repair using the Meniscal Viper Repair System

Purpose

This study examined the postoperative outcome of the all-inside arthroscopic meniscal suture repair technique using the Meniscal Viper Repair System for lateral meniscus tears.

Methods

Between January 2006 and December 2008, 57 patients (27 males and 30 females) with lateral meniscus tears who underwent meniscal repair using the Meniscal Viper Repair System were evaluated prospectively. Among them, 52 cases were tears involving the posterior third of the lateral meniscus, and most were longitudinal tears or bucket handle tears. The postoperative follow-up period ranged from 12 months to 4 years and 2 months, and averaged 19 months.

Results

Both Lysholm and Japanese Orthopaedic Association Score were significantly improved after surgery. Forty-nine of 57 patients (86.0 %) had no locking or catching, no joint line tenderness, and a negative McMurray test at the last follow-up. Of 32 patients who underwent second-look arthroscopy, 24 achieved complete healing, while four showed partial healing and required repeat repair, and four showed no healing and meniscectomy was conducted. The failure rate in all patients was thus 14.0 % (8 of 57 repairs). No major complications associated with the use of the Meniscal Viper Repair System were observed.

Conclusion

The Meniscal Viper System is a convenient and effective device for all- inside lateral meniscal suture, with high success rate and no major complications.