The role of arthroscopic surgery in the evaluation of acute traumatic hemarthrosis of the knee

Eighty patients presented for evaluation with an acute traumatic hemarthrosis of the knee and negligible instability on clinical examination. All had an examination under general anesthesia followed by arthroscopy. Anatomical lesions were demonstrated in 71 of 80 knees (89%) including anterior cruciate ligament (ACL) disruption in 50 (62%). Twenty-nine of 50 patients (58%) with arthroscopically-demonstrated ACL injuries had associated meniscal tears. Fifteen (19%) demonstrated isolated meniscal tears and nine (11%) osteochondral fractures not detected by conventional roentgenograms. The frequent occurrence of injuries to other joint structures in conjunction with ACL injuries was remarkable. An acute traumatic hemarthrosis of the knee often masks significant lesions. Arthroscopy aids the orthopedic surgeon in determining the full extent of the intraarticular damage.     

The outcome of nonoperatively treated complete tears of the anterior cruciate ligament in active young adults

The results of nonoperative treatment of 72 patients with complete anterior cruciate ligament (ACL) tears, documented by examination under anesthesia and arthroscopy, were evaluated. All patients had an acute injury with hemarthrosis in a previously normal knee. Patients having meniscal repair were excluded as were those with collateral or posterior cruciate ligament tears or associated fractures. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. A detailed rating of symptoms and function was performed at an average of 38 months postinjury (range, eight to 84 months). Overall results were 11% excellent, 20% good, 15% fair, and 54% poor. Thirty-five percent had ACL reconstruction during the follow-up period. Results indicate that young adults who return to a vocation requiring strenuous physical activity frequently can expect unsatisfactory results after nonoperative treatment of an acute complete tear of the ACL.     

Surgical or non-surgical treatment of acute rupture of the anterior cruciate ligament. A randomized study with long-term follow-up

One hundred and eleven consecutive patients who had acute injuries to the knee that included rupture of the anterior cruciate ligament, as shown by physical examination with the patient under anesthesia and by diagnostic arthroscopy, were randomized to three treatment groups: simple repair of all injured structures, repair of all injured structures and augmentation of the anterior cruciate ligament with a strip of the iliotibial band, and repair of all injured structures except the anterior cruciate ligament. In all other respects, the knees were treated in an identical fashion. Of the 111 patients, 107 were re-examined forty-five months or more after operation. At the most recent follow-up, the knees that had been treated by repair and augmentation of the anterior cruciate ligament were significantly more stable and had had significantly fewer subsequent meniscal tears. Sufficient instability to necessitate late reconstruction was also less frequent in the patients who had had an augmented repair. These patients had better function of the knee and a higher level of activity than the patients in the other two groups. Sixty-four per cent of these patients who had a rupture of the anterior cruciate also had a meniscal tear, and primary care was indicated for more than 50 per cent of the tears. Therefore, we believe that early arthroscopic examination is essential for patients who have an acute rupture of the anterior cruciate ligament.     

Magnetic resonance imaging of the knee in children and adolescents. Its role in clinical decision-making

BACKGROUND: Recent studies have questioned the utility of magnetic resonance imaging in the diagnosis of pediatric knee disorders because of the morphologic changes during growth and the low accuracy of the formal interpretation of the magnetic resonance imaging scan by a radiologist. The purpose of this study was twofold: (1) to report the accuracy of formal interpretations of magnetic resonance imaging scans of the knee in children and adolescent patients by a radiologist, and (2) to determine the benefit, if any, of a personal review of the magnetic resonance imaging scan of the knee by the orthopaedic surgeon, as a routine part of the diagnostic evaluation. METHODS: A three-year prospective study of all patients who underwent knee arthroscopy performed by a single surgeon, at two children's hospitals, was completed. The analysis focused on the six most common diagnoses: anterior cruciate ligament tear, lateral meniscal tear, medial meniscal tear, osteochondritis dissecans, discoid lateral meniscus, and osteochondral fracture. The preoperative diagnosis of the surgeon was determined by integrating the history and the findings on the clinical examination, plain radiographs, and magnetic resonance imaging scans (including the radiologist's interpretation). RESULTS: Ninety-six patients with ninety-six abnormal knees were included. The mean age was 14.6 years at the time of surgery. Relative to operative findings, kappa values for the formal interpretations of the magnetic resonance imaging scans by a radiologist were 0.78 for an anterior cruciate ligament tear, 0.76 for a medial meniscal tear, 0.71 for a lateral meniscal tear, 0.70 for osteochondritis dissecans, 0.46 for discoid lateral meniscus, and 0.65 for osteochondral fracture. Relative to operative findings, kappa values for the preoperative diagnoses by the surgeon were 1.00 for an anterior cruciate ligament tear, 0.90 for a medial meniscal tear, 0.92 for a lateral meniscal tear, 0.93 for osteochondritis dissecans, 1.00 for discoid lateral meniscus, and 0.90 for osteochondral fracture. The preoperative diagnosis by the surgeon was better (p < 0.05) than the formal interpretation of the magnetic resonance imaging scans by the radiologist with respect to an anterior cruciate ligament tear, lateral meniscal tear, osteochondritis dissecans, and discoid lateral meniscus. CONCLUSIONS: Integration of patient information with an orthopaedic surgeon's review of the magnetic resonance imaging scan of the knee in children and adolescent patients improves the identification of pathological disorders in four of the six categories evaluated. This study questions the necessity for and appropriateness of a routine interpretation of a magnetic resonance imaging scan of the knee in children and adolescents by a radiologist.     

Chondral injury associated with acute isolated posterior cruciate ligament injury.

SUMMARY: To evaluate associated cartilaginous damage with acute isolated posterior cruciate ligament (PCL) injury without other concomitant ligamentous injury, arthroscopic evaluations were performed on 61 consecutive patients. Meniscal tear was found in 17 cases (28%). Of these, 3 had medial meniscal tear, 11 had lateral meniscal tear, and 3 had both medial and lateral meniscal tears. Longitudinal tears of anterior segment in lateral menisci were the most common (10 cases). Thirty-two patients (52%) had articular cartilage injury. Of these, 7 had damage greater than one half of the thickness of the articular cartilage, and 3 had erosion that extended to the subchondral bone. The most frequently injured location was the medial femoral condyle (19 cases, 31%). Significant cartilaginous injury could be combined in acute isolated PCL injury. Therefore, it is unreasonable to manage every acute isolated PCL-injured knee using a single treatment modality. Concomitant meniscal and articular cartilaginous lesions should be evaluated when treatment for acute PCL injury is planned.     

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.     

Magnetic resonance imaging in the evaluation of tibial eminence fractures in adults

Proton density and T2-weighted sagittal, axial, coronal, and inversion recovery fat suppression magnetic resonance imaging (MRI) sequences were reviewed in 21 adults (10 men and 11 women) with 22 tibial eminence fractures. Average patient age was 43 years (range: 19-62 years). There were 3 type I, 3 type II, 12 type III, and 4 type IV fractures. The average fracture fragment size was 21 x 23 mm, and the average displacement was 5.5 mm (range: 0-12 mm). The MRI disclosed anterior cruciate ligament (ACL) insertional avulsions in 20 (91%), distal posterior cruciate ligament (PCL) avulsions in 4 (18%), intrasubstance ACL damage in 9 (41%), intrasubstance PCL injury in 3 (14%), medial collateral ligament (MCL) tears in 9 (41%) knees, retinacular injury in 8 (36%), posterolateral corner damage in 8 (36%), medial meniscal tears in 5 (23%), and 4 (18%) had lateral meniscal tears. Occult subchondral osseous injuries were seen in the posterolateral tibial plateau in 13 (59%) knees, anterolateral femoral condyle in 4 (18%), and posteromedial tibial plateau in 5 (23%) knees. Discrete osteochondral fractures were present in 7 (32%) knees. Significant osseous, cartilaginous, meniscal, and ligamentous damage was discovered in all patients. Based on these findings, we recommend MRI evaluation of all tibial eminence fractures to accurately detect all knee damage.     

Combined Meniscus Repair and Anterior Cruciate Ligament Reconstruction

Meniscal tear patterns associated with anterior cruciate ligament (ACL) tears, such as root tears and ramp lesions are common but less easily recognized on magnetic resonance imaging (MRI) compared with a complete radial tear or a locked bucket-handle tear. Timely treatment of these tears improves outcomes in the setting of ACL reconstruction. While physical examination does not enable a definitive diagnosis of meniscal root tears and ramp lesions, high-grade laxity, including a 3+ Lachman and 3+ pivot shift, should raise suspicions for these tear patterns. MRI allows visualization of both root tears and ramp lesions, although the gold standard for diagnosis is probing at the time of arthroscopy due to a high false-negative rate on MRI. Up to 17% of patients with an ACL tear have a lateral meniscal root tear; a contact mechanism and increased posterior slope are both associated with a greater incidence of lateral meniscal root tears and these are repaired with a tunnel technique. Meniscal ramp lesions occur in up to 41% of patients with ACL tears due to a contact mechanism, and we prefer repair with an inside-out technique. More than 60% of complete radial meniscal tears occur in the setting of ACL tears and are preferentially repaired with a hashtag technique for minimally separated tears and a 2-tunnel technique combined with an inside-out repair for more severe tears. Bucket-handle tears are more common in the setting of chronic ACL deficiency; concurrent with ACL reconstruction urgent meniscal repair with an inside-out technique is the gold standard, which allows for precise approximation of the tear with multiple points of fixation for improved biomechanical performance. It is critical to identify and treat these tears during ACL reconstruction because of their role as secondary stabilizers and for long-term chondral protection.     

Evaluation of knee instability in acute ligamentous injuries

The stability on clinical examination (CE) and examination under anaesthesia (EUA) was evaluated in 350 consecutive acute knee injuries. Valgus instability in knees with a medial collateral tear was observed on CE in 62 and on EUA in 67 cases (p less than 0.05). The anterior drawer sign was positive in 55 patients on CE and in 110 patients on EUA (p less than 0.0001), the corresponding figures for the Lachman test were 66 and 126 respectively (p less than 0.0001). The pivot shift-test was positive in 13 cases on CE and in 87 under anaesthesia (p less than 0.0001). Fresh total tears of the anterior cruciate ligament (confirmed at arthrotomy, n = 79) were detected by the Lachman test in 48 per cent on CE and in 96 per cent on EUA. Of the nine fresh, total tears of the posterior cruciate ligament three were disclosed by the posterior drawer test on CE and all nine on EUA. Anteromedial rotatory instability was observed on CE in 10 patients and on EUA in 47 (p less than 0.0001). In these patients 41 medial collateral tears, 23 posteromedial capsular tears, 21 medial meniscus and 40 anterior cruciate lesions were found. On CE only one anterolateral rotatory instability was found, whereas EUA disclosed 9 cases. Posteromedial rotatory instability was not confirmed on CE, though on EUA four cases were found. CE and EUA detected 2 and 3 posterolateral instabilities respectively. In conclusion, the use of EUA with an adequate mode of stability evaluation in acute knee injuries is strongly advocated. Clinical examination is considered highly unreliable with many false negative findings.     

Arthroscopic management of intra-articular low-velocity gunshot wounds of the knee

This article reports on the arthroscopic management of intra-articular low-velocity gunshot wounds. Thirteen (12 men and 1 woman) patients comprised the study population treated over a 5-year period. All patients underwent arthroscopy within 24 hours of injury. Four patients had additional limited arthrotomies for internal fixation of associated fractures and removal of an embedded bullet. Allograft reconstruction as a delayed procedure was required in 1 patient with extensive bone deficiency of the medial femoral condyle. Two patients suffered cruciate ligament tears: one avulsion fracture of the femoral attachment of the posterior cruciate ligament and one avulsion tear of the tibial attachment of the anterior cruciate ligament. Meniscal damage was observed in 2 patients, one of which required a primary repair. No infections or operative complications occurred. Arthroscopic evaluation of the affected knees allowed debridement of osteochondral loose bodies, retained foreign materials and bullet fragments, and also aided in surgical decision making.     

Acute traumatic knee effusions in children and adolescents

A prospective analysis was completed during a 6-month period to identify all patients, age 18 years or younger, who presented for evaluation of their knee effusion. There were 44 injured knees in 44 patients. There were a total of 55 diagnoses: 16 (29%) anterior cruciate ligament (ACL) injuries, 16 (29%) meniscal tears, 14 (25%) patellofemoral subluxations or dislocations, 3 (5%) medial collateral ligament sprains, 2 (4%) patellar osteochondral fractures, 2 (4%) retinacular injuries, 1 (2%) posterior cruciate ligament rupture, and 1 (2%) tibial eminence fracture. Girls had 11 of the 14 patellofemoral injuries; 58% of the girls had effusions secondary to patellofemoral pathology compared with 12% of the boys. Boys had 10 of the 16 meniscal tears and 13 of the 16 ACL tears. Fifty-two percent of boys had an injury to the ACL and 44% had an injury to a meniscus. In contrast, 16% of girls had an ACL injury and 32% had meniscal tears. ACL injuries, meniscal tears, and patellofemoral pathology accounted for 87% (48/55) of the diagnoses. Girls were more likely to have patellofemoral pathology; boys were more likely to have ACL and meniscal tears.     

Meniscal tears sustained awaiting anterior cruciate ligament reconstruction

We reviewed 68 patients who underwent anterior cruciate ligament (ACL) reconstruction after initial EUA & arthroscopy in the knee unit of a United Kingdom district general hospital. Mean time between injury and ACL reconstruction surgery was 23.3 months with the incidence of meniscal tear at reconstruction being 67.6%. In this series 10.3% of patients sustained a meniscal tear in the delay period between arthroscopy and reconstruction surgery. Meniscal tear is strongly associated with ACL rupture and also a poorer outcome following reconstruction surgery. The delay in diagnosis and wait for reconstruction surgery that patients experience are potentially worsening surgical outcomes in the anterior cruciate deficient knee.     

Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts

BACKGROUND: A prospective study was done to determine the functional results, patient satisfaction, and graft failure rate after fifty-seven consecutive revision replacements of the anterior cruciate ligament with use of a bone-patellar tendon-bone autogenous graft. METHODS: Fifty-four patients (fifty-five operations) were followed in this study. Concurrent operative procedures were performed during the revision procedure in thirty-seven knees (67%). These procedures included repair of a meniscal tear in twenty knees (36%) and reconstruction of deficient posterolateral or medial ligament structures in seventeen knees (31%). Nine knees (16%) had a high tibial osteotomy to correct varus malalignment before the revision operation. The results were evaluated with the Cincinnati Knee Rating System. RESULTS: There were significant improvements in the scores for pain (p < 0.0001), activities of daily living (p < 0.01), sports participation (p < 0.001), patient satisfaction (p < 0.0001), and overall rating of the knee (p < 0.0001). Thirty-three (60%) of the replaced ligaments were functional, nine (16%) were partially functional, and thirteen (24%) had failed. CONCLUSIONS: Many knees (93%) had compounding problems, including articular cartilage damage, prior meniscectomy, loss of secondary ligament restraints, varus malalignment, and concomitant ligament replacement or meniscal repair. Therefore, the results were generally less favorable than those following primary operations. The rate of graft failure was three times higher than our previously reported failure rate after primary replacements of the anterior cruciate ligament with a bone-patellar tendon-bone autogenous graft. Even so, symptoms and functional limitations with regard to daily and sports activities were found to have decreased and patient satisfaction improved. We advocate correction of varus malalignment prior to anterior cruciate procedures. Associated posterolateral ligament deficiencies should be surgically corrected during anterior cruciate procedures to prevent excessive loading on the graft from abnormal lateral tibiofemoral joint opening. Meniscal tears, including complex tears that extend into the avascular zone, can be concurrently repaired successfully during the revision.     

A perspective of lesions associated with ACL insufficiency of the knee. A review of 100 cases

A retrospective study was conducted to survey the extent of intracapsular damage associated with ACL insufficient knees in both the acute and chronic situation. Previously unoperated knees were studied to assess the effect that reinjury had on the knee joint. One hundred patients with confirmed anterior cruciate ligament damage, both clinically and under general anesthesia, were examined arthroscopically and the findings recorded on video tape. Both anterolateral and posteromedial approaches were used to well visualize the entire intra-articular structures of the knee joint. The incidence of meniscal tears increased from 77% in the acute injury to 91% in the chronically reinjured knee (p less than .06). Furthermore, articular surface disease increased from 23% in the acute injury to 54% in the chronically ACL lax knee (p less than .002). The majority of meniscal tears were medial and amenable to peripheral suture repair (63%). Irrespective of how one approaches ACL insufficiency of the knee acutely, one cannot ignore the likelihood of finding these significant associated lesions. Reinjury to the knee will likely enhance the incidence of meniscal tears and articular changes.     

The natural history of the meniscus in anterior cruciate insufficiency. Arthroscopic analysis.

We studied arthroscopically the meniscal pathology in 100 patients with functional instability of the knee from isolated rupture of the anterior cruciate ligament at an average time of three years after injury. Meniscal tears were observed in 86 patients and multiple lesions of both menisci were common. An incomplete longitudinal cleavage, visible on both surfaces of the posterior horn, was seen in more than half the knees and seemed to indicate progressive meniscal deterioration. Clinical examination was unreliable and we suggest that arthroscopic assessment is necessary for accurate diagnosis and staging.     

Unusual solitary ganglion cysts of the anterior segment of the lateral meniscus

Generally, ganglion or synovial cysts have been reported to originate from numerous structures in and around the knee joint, including the anterior cruciate ligament, posterior cruciate ligament, popliteal tendon, and menisci. Nevertheless, a ganglion is not a synovial cyst and there is no synovial lining. Meniscal cysts present a subgroup of ganglion cysts that occur in association with meniscal tears. We report 2 cases of unusual meniscal cyst from the anterior segment of the lateral meniscus without any meniscal tear and discuss the possibility of their pathogenesis and treatment.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: pp E16     

Combined reconstruction of the anterior cruciate ligament in competitive athletes

Fifty-eight professional and competitive amateur athletes had a combined reconstruction of the anterior cruciate ligament, with use of the semitendinosus tendon for the intra-articular portion of the reconstruction and a strip of iliotibial band for the extra-articular augmentation. Thirty patients (thirty-two knees) were evaluated two to seven years postoperatively to assess the results and the ability to return to athletics. Follow-up consisted of an interview, clinical and roentgenographic examinations, and testing with an arthrometer. Six patients (20 per cent) had a rating of excellent; twenty-two (73 per cent), good; and two (7 per cent), fair. There were no poor results. Of the thirty-two knees, twenty had an associated injury: twenty meniscal tears in eighteen knees, three tears of the medial collateral ligament, four osteochondral fractures of the lateral femoral condyle, and two loose bodies. Combined reconstruction of the anterior cruciate ligament resulted in improved stability of the knee in these patients whose goal of treatment was to be able to resume sports at a highly competitive level.     

The acutely ACL injured knee assessed by MRI: are large volume traumatic bone marrow lesions a sign of severe compression injury?

OBJECTIVES: To map by magnetic resonance imaging (MRI) and quantitative MRI (qMRI) concomitant fractures and meniscal injuries, and location and volume of traumatic bone marrow lesions (BMLs) in the acutely anterior cruciate ligament (ACL) injured knee. To relate BML location and volume to cortical depression fractures, meniscal injuries and patient characteristics. METHODS: One hundred and twenty-one subjects (26% women, mean age 26 years) with an ACL rupture to a previously un-injured knee were studied using a 1.5T MR imager within 3 weeks from trauma. Meniscal injuries and fractures were classified by type, size and location. BML location and volume were quantified using a multi-spectral image data set analyzed by computer software, edited by an expert radiologist. RESULTS: Fractures were found in 73 (60%) knees. In 67 (92%) of these knees at least one cortical depression fracture was found. Uni-compartmental meniscal tears were found in 44 (36%) subjects and bi-compartmental in 24 (20%). One hundred and nineteen (98%) knees had at least one BML, all but four (97%) located in the lateral compartment. Knees with a cortical depression fracture had larger BML volumes (P<0.001) than knees without a cortical depression fracture, but no associations were found between meniscal tears and BML volume or fractures. Older age at injury was associated with smaller BML volumes (P<0.01). CONCLUSION: A majority of the ACL injured knees had a cortical depression fracture, which was associated with larger BML volumes. This indicates strong compressive forces to the articular surface and cartilage at the time of injury, which may constitute an additional risk factor for later knee osteoarthritis development.     

Arthroscopic treatment of acute patellar dislocations

Twenty-nine patients treated with arthroscopy alone for acute patellar dislocation were reviewed. All had a significant traumatic episode with hemarthrosis in a previously asymptomatic knee. Clinical follow-up averaged 25 months (range 5-64 months). Fifteen patients had concomitant percutaneous lateral release (LR). Significant-sized osteochondral defects not radiographically visible preoperatively were discovered in 40%. Fragments were excised and corresponding craters debrided or abraded. Additional intraarticular pathology discovered included two meniscal tears and one anterior cruciate tear. Overall excellent (E) and good (G) results were 83%. The recurrence rate was 14%, all of which occurred in the LR group. All recurrent dislocations occurred within 1-year post injury. The LR group had 73% G and E results compared with 93% in those without LR. Arthroscopy followed by immobilization was an efficacious approach to acute traumatic patellar dislocations in this specific group of patients. The addition of LR with early motion, however, detracted from the results.     

Internal derangement of the knee: diagnosis by arthrography, arthroscopy, and arthrotomy

Three hundred eighty-four cases involving all patients with meniscal or anterior cruciate ligament tears were examined surgically by 16 orthopedic surgeons over two distinct 12-month periods. The incidence of both menisci (ipsilateral knee) torn was 3.9%, and the ratio of medial to lateral meniscal tears was 2.7:1. Twelve percent of cases had tears of the anterior cruciate ligament, 70% of which were found with a concomitant medial meniscus tear. Arthrography was completely accurate in 73.2% of cases, and arthroscopy was accurate in 94.9%. When clinical impression, arthrography, and arthroscopy were combined, the overall diagnostic accuracy was 96.8%.