Arthroscopic excision of an intra-articular osteoid osteoma at the knee

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.     

Loose body as an obstacle for posterolateral arthroscopic portal formation in the knee joint

In this report, we present a case with difficult arthroscopic posterolateral portal formation due to loose body located in posterior compartment. These loose bodies are responsible for pain, decreased range of motion and cartilage damage in the knee joint. By making the posterior trans-septal portal prior, posterolateral portal could be made without difficulty completing the planned arthroscopic procedure.     

Arthroscopic Cystectomy for Popliteal Cysts Through the Posteromedial Cystic Portal

In the treatment of patients with popliteal cysts (Baker’s cysts), we generally need to address the intra-articular pathologies, most commonly, medial meniscal tears and concomitant connecting valvular mechanisms responsible for the formation and recurrence of the cyst. We introduce here an arthroscopic technique that can treat the associated intra-articular pathology and correct the valvular mechanism of the capsular fold. The most important step is to locate the opening connection between the joint cavity and the popliteal cyst at the posteromedial compartment. The opening is found at the posteromedial side of the medial head of the gastrocnemius after inferior displacement of the capsular fold, which overlies the opening. It is helpful to rotate the bevel of the arthroscope upward to the 11-, 12-, and 1-o’clock positions for most effective visualization of the capsular fold. After the opening connection of the cyst is found, the capsular fold is resected with basket forceps and a shaver inserted through the posteromedial portal to correct the valvular mechanism. Furthermore, we have developed an additional “posteromedial cystic portal,” which is located directly above the popliteal cyst and can be effectively used in cystectomy, especially in treatment of cysts that consist of septa and nodules. Arthroscopic popliteal cyst removal with use of an additional posteromedial cystic portal can be effective in treating a cyst with multiple fibrous septa or membranes.     

Arthroscopic examination of the posteromedial compartment of the knee joint

Summary In a series of 356 arthroscopies of the knee joint 127 patients were explored by arthrotomy. A Storz arthroscope was introduced through the patellar tendon, and we alternated between the 30° and 70° optical systems in the same trocar sheath. The 30° system was used for inspection of the superior, anterior, medial and lateral compartments, and to lead the tip of the instrument to the posterior part of the joint. The 70° telescope was then used, providing a good view of the posterior cruciate ligament and the posterior horn of the menisci and their attachments. It also allowed direct inspection of the posterolateral and posteromedial compartments. No major diagnostic error was made by the arthroscopist in the 127 patients operated on as a result of the findings of endoscopic examination. Arthroscopy with the use of both 30° and 70° telescopes at the same session gives high diagnostic accuracy and detailed, exact pre-operative diagnosis.

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Résumé Sur une série de 356 arthroscopies du genou 127 patients ont été arthrotomisés. Un arthroscope de Storz est introduit au travers du tendon rotulien et l'on utilise alternativement les systèmes optiques de 30° et de 70° dans la même gaine de trocart. Le système de 30° sert à l'inspection des compartiments supérieur, antérieur, interne et externe, et à diriger l'extrémité de l'instrument jusqu'à la partie postérieure de l'articulation. Le système de 70° est ensuite utilisé, donnant une bonne vue du ligament croisé postérieur et de la corne postérieure des ménisques ainsi que de leurs insertions. Il permet également l'inspection directe des compartiments postéro-externe et postéro-interne. Chez les 127 patients opérés en fonction des résultats de l'endoscopie, aucune erreur majeure de diagnostic n'a été décelée. Grâce à l'utilisation simultanée des optiques de 30° etde 70°, l'arthroscopie donne des renseignements précis et permet un diagnostic pré-opératoire détaillé et exact.

     

Arthroscopic partial lateral meniscectomy in an otherwise normal knee: Clinical, functional, and radiographic results of a long-term follow-up study

Purpose: To determine the clinical, functional, and radiographic long-term results of patients who underwent arthroscopic partial lateral meniscectomy in an otherwise normal knee. Type of Study: This was a retrospective case-control study. Methods: Between 1982 and 1991, 107 arthroscopic partial lateral meniscectomies were performed; 75 of these patients had an isolated lateral meniscal tear and their data were evaluated using the Lysholm score and a questionnaire recording patients’ subjective satisfaction. Radiographic analysis was performed according to the Jäger-Wirth classification and Fairbank changes. Results: All 75 patients were examined by questionnaire, 55 underwent physical examination, and 58 had radiographic analysis. The follow-up period ranged from 5 to 15 years. Excellent and good Lysholm score results decreased from 77% at maximal improvement to 66% at follow-up; 43% of patients maintained their level of maximal improvement, 78% showed one or more Fairbank changes at follow-up, and using the Jäger-Wirth score, 84% showed radiographic deterioration. Conclusions: Although deterioration of functional and especially radiographic results occurred after arthroscopic partial lateral meniscectomy, the number of good results, even with mean follow-up of 12.3 years, is remarkable. There was a high percentage of radiographic changes in our study, but there is no significant correlation between them and subjective symptoms or between them and functional outcome. We believe that careful meniscectomy provides good results for a long period of time but, the longer the follow-up, the more radiographic changes have to be expected; when meniscal refixation is possible, it should be performed.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 946–952     

Arthroscopic excision of the ganglion in the posterior septum by posterior trans-septal portal: report of two cases

We report two cases of ganglion cysts in the posterior septum of the knee joint, one as parameniscal cyst from the posterior horn of the lateral meniscus extending to posterior septum, and the other as a cyst located in the posterior septum adjacent to the posterior cruciate ligament, which were both arthroscopically excised expediently by posterior trans-septal portal. The posterior compartment of the knee is not readily accessible by ordinary arthroscopic portals, and therefore has been considered as ‘blind spot’ conventionally. The posterior trans-septal portal is useful for assorted diagnostic or manipulative procedures in the posterior compartment of the knee.     

关节镜对膝关节髁间痛的诊治

[目的]探讨关节镜下膝关节髁间痛的病因并作出分型，根据不同的分型作出不同的治疗。[方法]对16例以髁间痛为主要症状患者的临床表现、X线等影像资料和关节镜下表现结合，进行总结后分型，并行关节镜下微创治疗。[结果]膝关节髁间痛可分为6种类型：股骨髁间窝狭窄型；胫骨髁间嵴增高型；胫骨前交叉韧带起点骨赘增生型；关节内游离体嵌顿型；滑膜过度增生型；混合型。关节镜下能将狭窄的髁间窝扩大成形，增生骨赘去除，游离体摘除，增生滑膜刨削。经过2～14个月的随访，髁间痛明显缓解或消失。根据Lysholm评分，由术前51．7分增加至89．7分。[结论]关节镜微创术是治疗膝关节髁间痛的有效方法。     

关节镜下常规入路联合后内侧入路重建后交叉韧带

后交叉韧带（PCL）是维持膝关节稳定的一条重要韧带，随着对后交叉韧带的生理解剖功能及其损伤后继发的膝关节病变研究的深入，越来越倾向于对PCL进行积极的外科重建，以达到维持膝关节后向稳定性和防止骨性关节炎发生的目的。但由于后交叉韧带的解剖位置深在，重建中制作胫侧骨道时其后交叉韧带下位止点显露困难，给韧带重建带来难题。2003-2005年在关节镜下联合后内侧入路重建后交叉韧带15例，取得满意效果，报告如下。     

Arthroscopic partial meniscectomy of a posteriorly flipped superior leaflet in a horizontal medial meniscus tear using a posterior transseptal portal

This article describes a case of an arthroscopic partial meniscectomy of a posteriorly flipped superior leaflet in a horizontal medial meniscus tear using the posterior transseptal portal. An arthroscopic partial meniscectomy for bucket handle or flap tears in medial or lateral compartments using ordinary portals is a relatively common procedure in irreparable cases. However, the posterior compartment of the knee is not readily accessible through ordinary arthroscopic portals. Therefore, it has been considered a blind spot. Through the posterior transseptal portal, surgeons can achieve excellent arthroscopic visualization of the posterior compartment and easily perform arthroscopic procedures of the posterior compartment of the knee. A 48-year-old woman presented with a 1-year history of pain in the medial aspect of the right knee joint. Preoperative magnetic resonance imaging revealed a thinning of the medial meniscus posterior horn in coronal images and a sharp-edged triangle arising from the medial meniscus posterior horn between the medial femoral condyle and medial meniscus posterior horn on sagittal images (flipped-over sign). During the arthroscopic procedure, we found that the flipped leaflet was displaced posteriorly and was not mobile between the medial femoral condyle and medial meniscus posterior horn. Partial meniscectomy for a posteriorly displaced fragment can be performed successfully using the posterior transseptal portal. The posterior transseptal portal is useful for an arthroscopic partial meniscectomy of a posteriorly flipped leaflet in the posterior compartment of the knee.     

Arthroscopic subtalar arthrodesis through the sinus tarsi portal approach: A series of 77 cases

Background

Subtalar arthrodesis through an open approach carries significant risk of complications. An arthroscopic approach aims to minimise damage to the soft tissue envelope to improve recovery, union and complication rates. A two portal approach through the sinus tarsi was used.

关节镜下滑膜切除术治疗类风湿性关节炎

目的:评价关节镜下滑膜切除术在治疗类风湿性关节炎中的价值。方法:对40例早中期类风湿性关节炎48个膝关节(男10个,女38个,平均年龄35岁)在关节镜下行滑膜切除术,并使用双极射频汽化仪对残留的滑膜进行处理。术后给予羟基氯喹、氨甲喋呤和柳氮磺胺吡啶等抗类风湿药治疗,疗程6~12个月。48个关节均得到了6个月的随访,34个关节得到2年的随访。随访包括近侧指间关节的疼痛、关节压痛及关节肿胀的改善率;Ishikawa关节功能的评分;术前术后血沉(ESR)、C反应蛋白(CRP)和类风湿因子(RF)的检测。结果:早期类风湿性关节炎以滑膜充血水肿为主要特点,中期类风湿性关节炎在镜下的表现是血管翳和肉芽肿的形成,术后6个月近侧指间关节的疼痛、关节压痛及关节肿胀的总改善率为83.3%,术后2年为55.9%。Ishikawa关节功能的评分术后6个月总优良率为93.8%,术后2年为73.5%。ESR、CRP和RF均较术前明显下降。结论:对早中期类风湿性关节炎患者应进行关节镜下滑膜切除术,同时术后给予正规的药物治疗。     

Arthroscopic retrieval of a very rare penetrating foreign body of the knee

We report the very rare case of an 8-year-old boy who accidentally fell on the ground, causing the lead of a pencil to penetrate his left knee joint cavity. After radiographic diagnosis, the pencil was removed by a physician at a private clinic and the boy was referred to our department for further evaluation. We performed arthroscopic retrieval of the pencil lead through standard arthroscopic portals without an accessory portal. Postoperatively, the patient had a quick recovery without problematic sequelae.     

Injuries of the posterior cruciate ligament and posterolateral corner of the knee

Injuries of the posterior cruciate ligament (PCL) and posterolateral corner (PLC) of the knee are less common than those of the anterior cruciate ligament (ACL) and their significance is often under-appreciated in the acute setting. Even when recognised, knowledge of the natural history and outcome of treatment has lagged behind that of the ACL and has led to confusion over the indications for operative treatment. Recent developments in the understanding of the anatomy and biomechanics of this area of the knee have led to improvements in management and a renewed interest in these potentially disabling injuries. The aim of this review is to bring the trauma generalist abreast of these recent developments and to improve diagnosis through a heightened index of suspicion and use of appropriate special investigations. The principles of management of both isolated and combined injuries to the PCL and PLC, in the acute and chronic settings, are described.     

Topographical histology of the posterolateral corner of the knee, with special reference to laminar configurations around the popliteus tendon: a study of elderly Japanese and late-stage fetuses

We investigated the histology of laminar configurations at the posterolateral corners of 40 knees (18 late-stage fetuses, 22 elderly persons). In the fetuses, the deeply located popliteal fascia and the superficially located inferior geniculate vascular sheath were evident in a space between the popliteus tendon (PT) and the biceps femoris and gastrocnemius. Along, and deep to, the popliteal fascia, the popliteus muscle parenchyma developed into both the PT and another dense connective tissue mass. The PT attached to the fibula (i.e., the fetal popliteofibular ligament) and to the base of the lateral meniscus (i.e., the fetal popliteomeniscal fasciculus). This laminar configuration was essentially maintained in the elderly. The fetal dense connective tissue of the popliteus origin seemed to correspond to the adult arcuate ligament. However, because a connective tissue complex (including the PT and the arcuate and popliteofibular ligaments) was often well developed, the complex involved the inferior geniculate vascular sheath and popliteal fascia. A spectrum of variations was found in how thickly the complex developed. Thus, clear separation of the PT from the surrounding tissues often became difficult. Notably, the connective tissue complex could be peeled in different manners, depending on the site and the individual. Therefore, macroscopic variation in the posterolateral corner, including the apparent absence of some ligaments, seemed to be related to the thickness and number of layers developed by the connective tissue complex, possibly due to an adaptation to the individuals mechanical environment during growth and aging.     

The posterolateral corner of the knee. Anatomy, biomechanics and management of injuries

The structures within the posterolateral corner of the knee have recently been "re-discovered" providing a very important role in maintaining the stability of the knee. Injury to the posterolateral corner is not common but neither is it rare; it is usually damaged in combination with rupture of one of the cruciate ligaments in direct and indirect trauma to the knee. When reconstructing a knee to restore stability following such injuries, it is important to recognise damage to the posterolateral corner so that this can be corrected. Ignored damage to this region may result in continuing knee instability and resultant failure of cruciate ligament reconstruction. We present a review of the anatomy and biomechanics of the structures in the posterolateral corner. This is then related to the diagnosis of injuries to the region via history, examination and imaging. We then discuss the management of injuries to the posterolateral corner describing our preferred method of repair.     

膝关节后交叉韧带合并后外侧角损伤

[目的]探索膝关节后交叉韧带(PCL)合并后外侧角(PLC)损伤的临床特征,评估同期关节镜下四股腘绳肌腱单束重建膝PCL和后1/2股二头肌腱重建PLC的技术和效果。[方法]自2001年12月～2004年12月,14例病人(14膝)重度膝关节不稳入住本科,均表现为3+后抽屉试验阳性,内翻试验阳性,外旋试验患膝较健侧>10°,关节镜检查证实为PCL断裂,膝后外侧间隙张开,外侧半月板抬高,腘肌腱断裂。2例伴腓总神经损伤。均于关节镜下行自体四股腘绳肌腱单束PCL重建术,后侧1/2股二头肌腱PLC重建术。[结果]本组术后早期均未发生严重并发症。14例均获得随访,随访时间12～33个月,平均(21.14±7.26)个月。膝关节后侧稳定性有非常明显进步。膝关节伸直位、屈曲30°位内翻试验均为阴性。膝关节屈曲30°、90°位外旋试验双侧差均<10°。Lysholm膝关节功能评分为70～95分,平均(86.79±7.23)分,较术前(40～60)分,平均(47.14±8.25)分)明显改进(P<0.01)。IKDC综合评定正常(A级)4膝、接近正常(B级)9膝、异常(C级)1膝,较术前[异常(C级)3膝、显著异常(D级)11膝]有非常明显的改进(Z=3.296,P<0.001)。14例患者中,12例恢复伤前运动水平,2例运动水平较伤前减低。[结论]PCL损伤常合并PLC损伤,表现为重度后侧不稳和后外侧旋转不稳。关节镜下单束重建膝PCL,同期后侧1/2股二头肌腱重建PLC,手术损伤小、术后膝关节功能恢复满意。     

急性膝关节后外侧韧带结构损伤的治疗

目的总结急性膝关节后外侧韧带结构损伤的治疗方法,评估临床治疗效果。方法对27例急性膝关节后外侧韧带结构损伤的患者,根据不同损伤类型分别进行修复或重建。通过随访,了解膝关节后外侧韧带结构的稳定性。结果术后1年,无完全伸膝位内翻不稳,屈膝30°的Ⅰ°内翻不稳1例,伴硬性终止点,其余无内翻不稳;屈膝30°小腿外旋增加3例,均小于10°,相同16例,减小8例。结论对急性膝关节后外侧韧带结构损伤,早期治疗能够满意恢复其功能完整性。     

A mini-invasive technique for severe arthrofibrosis of the knee: A technical note

PurposeIn this article, a mini-invasive technique is described, which consists of arthroscopic adhesiolysis and quadriceps pie-crusting lengthening basing on pre-operative sonographic examination. Sonographic diagnostic value of quadriceps tendon fibrosis is also evaluated.MethodsPre-operative sonographic examination was performed to make an accurate location diagnosis of quadriceps fibrosis. After arthroscopic adhesiolysis, percutaneous pie-crusting release was performed basing on preoperative sonographic examination. An 18-gauge needle was used to puncture the stiff fibrous band of the distal and lateral quadriceps tendon under maximum knee flexion. The contractural quadriceps tendon is gradually released after 60–100 needle punctures.ResultsThis technique was performed in five post-traumatic stiff knees and three stiff knees after previous infection. The contractural rectus femoris tendon is average 22% thinner than contralateral parts according to sonographic measurement. Mean maximum flexion increased from 35° preoperatively to 80° after arthroscopic adhesiolysis and 120° after pie-crusting.ConclusionsThis technique is a simple, effective and mini-invasive method, allowing an immediate, aggressive rehabilitation postoperatively. Pre-operative sonographic location of quadriceps tendon fibrosis could potentially improve the efficacy and accuracy of percutaneous pie-crusting procedures.     

Multi-factorial sustainability approach is necessary to preserve knee function following osteoarthritis diagnosis

Knee function preservation following a diagnosis of osteoarthritis may benefit from healthy patient lifestyles, exercise or activity habits, and daily living routines. Underlying societal issues and social roles may contribute further to both ecological and knee function preservation concerns. Based on sustainability theory and social ecology concepts we propose that factors such as health history, genetic predisposition, socio-environmental factors and local-regional-global physiological system viability contribute to knee function preservation. Addressing only some of these factors or any one factor in isolation can lead the treating physician, surgeon and rehabilitation clinician to less than optimal treatment effectiveness. An example is presented of a 57-year-old man with medial tibiofemoral osteoarthritis. In the intervention decision-making process several factors are important. Patients who would benefit from early knee arthroplasty tend to place osteoarthritic knee pain elimination at the top of their list of treatment expectations. They also have minimal or no desire to continue impact sport, recreational or vocational activities. In contrast, patients who are good candidates for a knee function preservation treatment approach tend to have greater expectations to be able to continue impact sport, recreational or vocational activities, are willing and better able to implement significant behavioral changes and develop the support systems needed for their maintenance, are willing to tolerate and live with minor-to-moderate intermittent knee pain, and learn to become more pain tolerant.     

Total knee arthroplasty in the valgus knee using a standard medial approach

Total knee arthroplasty in the valgus knee poses specific problems to the surgeon, such as the presence of ligament tightness on the lateral side. It has been claimed in the past that approaching the knee from the lateral side through a lateral parapatellar arthrotomy may therefore be a more logical and easier technique than the standard medial approach used conventionally. Many surgeons however do not wish to change their routine practice and therefore wish to stick to the classical medial approach they are used to, even in the presence of an underlying valgus deformity. In this paper, we therefore report the technical considerations that one should take into account when addressing the valgus knee through a standard medial approach. These include tightness of the lateral soft tissues, stretching of the medial collateral ligament, lateral bowing of the femoral shaft, and a tendency for lateralized patellar tracking. A review of 125 consecutive valgus knees treated at our institution through a standard medial approach while using these principles, has demonstrated an excellent operative outcome in the majority of cases.