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Srisuwanporn P, Laksawut S, Tanulugpairoj J, Chinakarn Y, Khunvejvaidya P, Thantong B. The residual laxity of medial collateral ligament after magic point pie crusting MCL released in arthroscopic management of medial meniscus. Asia Pac J Sports Med Arthrosc Rehabil Technol 2024; 38:36-42. [PMID: 39380708 PMCID: PMC11460367 DOI: 10.1016/j.asmart.2024.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 08/11/2024] [Accepted: 09/01/2024] [Indexed: 10/10/2024] Open
Abstract
Background In order to do arthroscopic surgery on medial meniscus injuries, there must be enough joint space and good visibility for instrumentation. There is a possibility of iatrogenic cartilage damage if the medial joint space is reduced. Therefore, a medial collateral ligament (MCL) releasing procedure may be necessary for the majority of individuals with medial knee tightness. The MCL residual laxity after pie-crusting release during arthroscopic medial meniscus repair in medial knee tightness were studied in this study. Methods Between July 2022 and June 2023, fourteen patients (4 male, 10 female) underwent medial meniscus surgery with pie-crusting release of the superficial MCL. Mean age was 50 ± 10 years (range, 35-63 years). Medial meniscal lesions were meniscus root tear in 10 cases (71.5 %), longitudinal tear in 2 (14.5 %), horizontal tear in 1 (7 %) and radial tear in 1 (7 %). Preoperatively, valgus stress radiographs were obtained. During surgery if arthroscopic exploration revealed medial joint space narrowing after applying valgus force with the knee in 20 degrees of flexion, pie-crusting MCL release was performed. At the 3-month follow-up, valgus stress radiographs were obtained. Residual MCL laxity was assessed by comparing preoperative and 3-month follow-up medial joint space width measurements. Result At the 3-month follow-up, no significant increase in the medial joint space width on valgus stress radiograph was observed in comparison to the preoperative. The medial joint space width on valgus stress radiograph was 7.42 ± 1.16 mm preoperatively and 7.47 ± 1.15 mm at 3-month postoperatively (p value = 0.914). All patients had no intraoperative iatrogenic cartilage injury and no saphenous nerve injury after operation. Conclusions The magic point pie-crusting MCL release is a reliable and useful procedure to arthroscopic surgery in patients with medial meniscal injury and medial knee tightness. Furthermore, percutaneous pie-crusting MCL release had no effect on residual valgus laxity at the last follow-up.
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Affiliation(s)
- Pinij Srisuwanporn
- Sports Medicine Service, Department of Orthopedics, Rajavithi Hospital, Bangkok, Thailand
| | - Suriya Laksawut
- Sports Medicine Service, Department of Orthopedics, Rajavithi Hospital, Bangkok, Thailand
| | - Jiradeth Tanulugpairoj
- Sports Medicine Service, Department of Orthopedics, Rajavithi Hospital, Bangkok, Thailand
| | - Yottawee Chinakarn
- Sports Medicine Service, Department of Orthopedics, Rajavithi Hospital, Bangkok, Thailand
| | - Phichit Khunvejvaidya
- Sports Medicine Service, Department of Orthopedics, Rajavithi Hospital, Bangkok, Thailand
| | - Banchong Thantong
- Biomedical Engineering, Department of Medical Innovation, Rajavithi Hospital, Bangkok, Thailand
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Malinowski K, Kim DW, Kennedy NI, Pękala PA, LaPrade RF, Mostowy M. Arthroscopic Trans-septal Portal of the Knee With Direct Visualization and No Need for Posterolateral Portal Creation. Arthrosc Tech 2023; 12:e2369-e2374. [PMID: 38196868 PMCID: PMC10773255 DOI: 10.1016/j.eats.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/13/2023] [Indexed: 01/11/2024] Open
Abstract
Arthroscopic visualization and access of the posterior knee are limited when using standard anterior and posterior portals. The creation of a trans-septal portal allows for complete access to the posterior compartment as arthroscopic instruments are able to be passed back and forth between the posteromedial and posterolateral compartments. Due to the close proximity of the popliteal artery and its branches, precise portal placement and safe orientation of arthroscopic instruments are critical to avoid iatrogenic injury. The conventional technique of trans-septal portal creation, involving a posterolateral portal, can be difficult in some cases. To overcome these obstacles, a posteromedial technique of trans-septal portal creation is presented. By using the medial parapatellar portal as the viewing portal, our technique allows for direct visualization of the posterior septum on each step of creation of the trans-septal portal, eliminating the need for "blind" maneuvers. What is more, no posterolateral portal is needed, decreasing the risk of potential complications. Using the posterior cruciate ligament fibers as a main landmark for trans-septal portal placement, preservation of the posterior part of the septum is achieved. This ensures optimal safe-margin distance away from the popliteal neurovascular bundle and making the technique safe and reproducible.
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Affiliation(s)
- Konrad Malinowski
- Department of Anatomy, Jagiellonian University Medical College, International Evidence-Based Anatomy Working Group, Kraków, Poland
- Artromedical Orthopedic Clinic, Bełchatów, Poland
| | - Dong Woon Kim
- Department of Anatomy, Jagiellonian University Medical College, International Evidence-Based Anatomy Working Group, Kraków, Poland
| | | | - Przemysław A. Pękala
- Department of Anatomy, Jagiellonian University Medical College, International Evidence-Based Anatomy Working Group, Kraków, Poland
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
- Lesser Poland Orthopedic and Rehabilitation Hospital, Kraków, Poland
| | | | - Marcin Mostowy
- Artromedical Orthopedic Clinic, Bełchatów, Poland
- Orthopedic and Trauma Department, Veterans Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
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Pires D, Monteiro L, Rocha de Faria JL, Albuquerque RSPE, Astur D, Pádua VBCD, Salim R, LaPrade RF. Diagnosis by Manual Maneuver of Medial Meniscus Ramp Lesions. Arthrosc Tech 2023; 12:e959-e964. [PMID: 37424638 PMCID: PMC10323914 DOI: 10.1016/j.eats.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/22/2023] [Accepted: 02/14/2023] [Indexed: 07/11/2023] Open
Abstract
The intra-articular injury most often associated with a chronic anterior cruciate ligament tear involves the posterior horn of the medial meniscus. A specific type of medial meniscal injury, called a ramp lesion, has received greater attention for identification and treatment because of its considerable incidence and diagnostic difficulty. Based on their location, these lesions may be arthroscopically "hidden" during traditional anterior visualization. The purpose of the present Technical Note is to describe the Recife maneuver. This maneuver diagnoses injuries to the posterior horn of the medial meniscus using additional arthroscopic management through a standard portal. The Recife maneuver is performed with the patient in the supine position. A 30° arthroscope is inserted through the anterolateral portal, and the posteromedial compartment is accessed according to the transnotch view (modified Gillquist view). In the proposed maneuver, with the knee in 30° of flexion, a valgus stress with internal rotation is performed, followed by palpation of the popliteal region and digital pressure on the joint interline. This maneuver allows a greater visualization of the posterior compartment, allowing the diagnostic evaluation of the integrity between the meniscus and the capsule, in a safer way, being able to identify ramp tears without the need to create a posteromedial portal. We recommend that the addition of the diagnostic visualization step of the posteromedial compartment as described by the Recife maneuver be performed to assess the meniscal status in routine anterior cruciate ligament reconstruction.
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Affiliation(s)
- Diego Pires
- Integral Medicine Institute Prof Fernado Figueira Recife, PE, Brazil
| | | | - José Leonardo Rocha de Faria
- Knee Surgery Center of the National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, RJ, Brazil
- School of Medicine from University of São Paulo, USP Riberão Preto, SP, Brazil
| | | | | | | | - Rodrigo Salim
- School of Medicine from University of São Paulo, USP Riberão Preto, SP, Brazil
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Hauer TM, Wengle LJ, Whelan DB. Adjuvant Medial Collateral Ligament Release at the Time of Knee Arthroscopy: A Controlled Percutaneous Technique. Arthrosc Tech 2022; 11:e1541-e1546. [PMID: 36185117 PMCID: PMC9519794 DOI: 10.1016/j.eats.2022.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/25/2022] [Indexed: 02/03/2023] Open
Abstract
The posterior horn of the medial meniscus can be challenging to view during arthroscopy because the medial femoral condyle obstructs vision, especially in tight medial compartments. Previous studies have described techniques for improving access, one being a percutaneous medial collateral ligament (MCL) release. This technique allows for increased medial compartment space, which offloads a tight medial compartment, minimizes iatrogenic chondral injury, incomplete meniscal resection, uncontrolled MCL rupture, and allows for accurate diagnosis and management. Studies have proven the safety of the controlled percutaneous MCL release, with no significant postoperative MCL laxity on stress views, no subjective patient instability, fewer iatrogenic cartilage lesions, and no saphenous neurovascular injury. Furthermore, retrospective studies have shown improved postoperative patient-reported outcomes with a controlled percutaneous MCL release in comparison to standard of care without a release. We hypothesize that a controlled percutaneous release of the MCL effectively alleviates some of the pressure within the medial compartment, which could potentially explain the improved postoperative clinical outcomes. This technique also facilitates improved visualization, a decreased risk of iatrogenic chondral injury, and a more complete meniscal resection. The purpose of this Technical Note is to describe our surgical technique and provide surgical pearls for a controlled percutaneous MCL release during knee arthroscopy.
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Affiliation(s)
- Tyler M. Hauer
- Address correspondence to Tyler M. Hauer, M.D., University of Toronto Orthopaedic Sports Medicine (UTOSM), Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, 149 College St, Toronto, Ontario, Canada M5T 1P5.
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Ramp lesion repair via dual posteromedial arthroscopic portals: A cadaveric feasibility study. Orthop Traumatol Surg Res 2022; 108:103175. [PMID: 34906726 DOI: 10.1016/j.otsr.2021.103175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Ramp lesions are found in 16% to 40% of patients undergoing anterior cruciate ligament reconstruction. The repair technique traditionally involves using a suture hook through a posteromedial portal, with the arthroscope positioned in the intercondylar view via an antero-lateral portal. Ramp lesions may be difficult to visualize and repair, even with a 70° arthroscope. The objective of this study was to assess the feasibility of suturing ramp lesions via dual posteromedial portals for the arthroscope and instruments. HYPOTHESIS Dual posteromedial arthroscopic portals allow good visualisation and high-quality suturing of ramp lesions, without inducing specific iatrogenic injuries. MATERIAL AND METHODS We used 11 fresh cadaver knees. Two posteromedial portals were created under visualisation via an arthroscope introduced through an antero-lateral portal: one was the traditional instrumental portal and the other, located more proximally, was the optical portal. A 2-cm long ramp lesion was created. A suture hook was used to place one or two stitches of PDS n°0 suture. A probe was used to test the quality and stability of the suturing. The posteromedial plane was then dissected to evaluate the anatomical relationships of the portals. RESULTS The dual posteromedial approach allowed the visualisation and hook suturing of the ramp lesions in all 11 cases. A single stitch was placed in 4 cases and two stitches in 7 cases. The suture was always of good quality and stable when tested with the probe. The dissection found no injuries to nerves, blood vessels, or tendons. CONCLUSION Ramp lesions can be repaired through a dual posteromedial arthroscopic approach. This surgical technique provides good visibility of these lesions and allows high-quality suturing, with no specific iatrogenic injuries. It is an alternative to ramp lesion repair via a single posteromedial portal, which can be challenging. LEVEL OF EVIDENCE IV, experimental study with no control group.
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da Silva Campos VC, Guerra Pinto F, Constantino D, Andrade R, Espregueira-Mendes J. Medial collateral ligament release during knee arthroscopy: key concepts. EFORT Open Rev 2021; 6:669-675. [PMID: 34532074 PMCID: PMC8419794 DOI: 10.1302/2058-5241.6.200128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Complete access to the posterior medial compartment of the knee may represent a technical challenge during arthroscopy in patients with a tight tibiofemoral joint space. Medial collateral release reduces direct iatrogenic cartilage damage in the medial compartment of the knee through manipulation with instruments. We recommend performing medial collateral release in surgeries that access the posteromedial compartment (e.g. partial meniscectomy for ruptures of the posterior horn of medial meniscus or posterior root repairs) when the patient has a tight tibiofemoral joint space. There are two main techniques to perform medial collateral release: inside-out and outside-in. Regardless of the technique used, releasing medial ligament structures is a safe and effective method to be used in the diagnosis and treatment of injuries to the medial compartment. Cite this article: EFORT Open Rev 2021;6:669-675. DOI: 10.1302/2058-5241.6.200128
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Affiliation(s)
| | - Francisco Guerra Pinto
- Hospital Ortopédico de Sant'Ana, Hospital Cruz Vermelha Portuguesa, Universidad de Barcelona, Nova Medical School, Lisboa, Portugal
| | | | - Renato Andrade
- Clínica Do Dragão, Espregueira-Mendes Sports Centre - FIFA Medical Centre of Excellence, Porto, Portugal.,Porto Biomechanics Laboratory (LABIOMEP), Faculty of Sports, University of Porto, Porto, Portugal
| | - João Espregueira-Mendes
- Clínica Do Dragão, Espregueira-Mendes Sports Centre - FIFA Medical Centre of Excellence, Porto, Portugal.,Dom Henrique Research Centre, Porto, Portugal.,ICVS/3Bs, PT Government Associate Laboratory, Braga/Guimarães, Portugal.,School of Medicine, Minho University, Braga, Portugal
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Sebro R, Ashok SS, Uriell M. Association between tears of the posterior root of the medial meniscus and far posterior femoral condyle osteoarthritis. ACTA ACUST UNITED AC 2021; 26:349-354. [PMID: 32558651 DOI: 10.5152/dir.2019.19358] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate whether tears of the posterior horn of the medial meniscus root ligament (PHMM RL) are associated with osteoarthritis of the far posterior femoral condyles (FPFC). METHODS Retrospective review of 1158 patients who underwent arthroscopy identified 49 patients with confirmed tears of the medial meniscus posterior root ligament attachment. Preoperative magnetic resonance imaging (MRI) studies were reviewed to identify advanced osteoarthritis involving the medial and lateral FPFC. Control patients (n=48) had no meniscal tears confirmed by arthroscopy. Cases and controls were age- and sex-matched exactly 1:1. One case patient was excluded since there was no age- and sex-matched control available. The International Cartilage Research Society (ICRS) MRI cartilage grade was recorded for the medial and lateral FPFC. Associations were evaluated using univariate and multivariable conditional logistic regression analyses. RESULTS There were 48 case and 48 control patients (10 men in each group, 20.8%) with median age 53 years (range, 21-67). Medial FPFC ICRS Grade 2 or higher lesions were present in 34 (70.8%) of case patients and 16 (33.3%) of control patients. Lateral FPFC ICRS Grade 2 or higher lesions were present in 24 (50%) of case patients and 14 (28.2%) of control patients. Increased body mass index (BMI) was associated with PHMM RL tears (OR=1.11, 95% CI [1.01, 1.22], P = 0.020). MRI was 81.2% (39/48) sensitive and 91.2% (44/48) specific for detection of PHMM RL tears. PHMM RL tears were associated with Grade 2 or higher medial FPFC osteoarthritis (OR=10.00, 95% CI (2.34, 42.78), P < 0.001). This association remained after adjusting for BMI (OR=11.79, 95% CI [2.46, 56.53], P = 0.002). There was also an association between PHMM RL tears and lateral FPFC osteoarthritis, which persisted after adjusting for BMI (OR =3.00, 95% CI [1.07, 8.37], P = 0.036). CONCLUSION PHMM RL tears are associated with advanced osteoarthritis of the FPFC. Radiologists identifying FPFC osteoarthritis should look carefully for PHMM RL tears.
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Affiliation(s)
- Ronnie Sebro
- Department of Radiology, Pennsylvania University School of Medicine, Philadelphia, USA;Department of Orthopedic Surgery, Pennsylvania University School of Medicine, Philadelphia, USA;Department of Genetics , Pennsylvania University School of Medicine, Philadelphia, USA;Department of Epidemiology and Biostatistics, Pennsylvania University School of Medicine, Philadelphia, USA
| | - S Sharon Ashok
- Department of Radiology, Pennsylvania University School of Medicine, Philadelphia, USA
| | - Matthew Uriell
- Department of Radiology, Pennsylvania University School of Medicine, Philadelphia, USA
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Ganokroj P, Lertwanich P, Chandhanayingyong C, Keyurapan E, Vanadurongwan B. Arthroscopic Treatment of a Large Mass of the Medial Side of the Leg Caused by Distal Extension of a Meniscal Cyst: A Case Report. JBJS Case Connect 2020; 10:e0127. [PMID: 32649093 DOI: 10.2106/jbjs.cc.19.00127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report a 39-year-old man who presented with a painful mass that had been growing over the anteromedial aspect of his left leg for 2 years and was recurrent after an open excisional biopsy. Magnetic resonance imaging showed a lobulated cyst that extended from the medial meniscus. Arthroscopic cyst decompression, anterior cruciate ligament reconstruction, partial meniscectomy, and repair of the meniscotibial capsule were performed. There was no recurrence during the 1-year follow-up. CONCLUSIONS Arthroscopic cyst decompression and repair of the posterior meniscotibial capsule is a good and safe alternative procedure for the treatment of large-sized meniscal cysts with distal extensions.
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Affiliation(s)
- Phob Ganokroj
- 1Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Gaudiani MA, Knapik DM, Kaufman MW, Salata MJ, Voos JE, Karns MR. Percutaneous Superficial Medial Collateral Ligament Release Outcomes During Medial Meniscal Arthroscopy: A Systematic Review. Arthrosc Sports Med Rehabil 2020; 2:e153-e159. [PMID: 32368752 PMCID: PMC7190537 DOI: 10.1016/j.asmr.2019.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/21/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To systematically review the literature to better understand the technique, outcomes, and complications after percutaneous superficial medial collateral ligament (sMCL) lengthening during knee arthroscopy to address isolated medial meniscal pathology. Methods A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using a PRISMA checklist. The inclusion criteria consisted of English-language articles or articles with English-language translations documenting the use of percutaneous sMCL lengthening during arthroscopic knee surgery to treat isolated meniscal pathology (repair vs meniscectomy) with reported postoperative outcomes and complications. Results Four studies met the inclusion criteria, consisting of a total of 192 patients undergoing percutaneous sMCL lengthening. No perioperative complications related to iatrogenic chondral damage, fracture, or additional meniscal injury were reported. Mild postoperative pain at the medial needle tract site lasting up to 15 days after surgery was reported in 52% of patients (46 of 88). At final follow-up, laxity on valgus stress testing showed a range from 0 to 1.1 mm with a range from –0.3° to 0.9° of radiographic medial joint space widening compared with preoperative radiographs. The length of follow-up ranged from 1.5 to 24 months. Conclusions The percutaneous “pie-crusting” technique remains the most commonly reported technique to lengthen the sMCL during arthroscopic meniscal surgery. Percutaneous lengthening represents a safe and effective method of increasing medial joint space visualization, with no reported perioperative or postoperative complications and with minimal, likely clinically insignificant residual joint laxity after surgery on valgus stress testing at final follow-up compared with preoperative values. Level of Evidence Level IV, systematic review of Level IV studies.
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Affiliation(s)
- Michael A Gaudiani
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Derrick M Knapik
- University Hospitals Sports Medicine Institute, Cleveland, Ohio, U.S.A
| | - Matthew W Kaufman
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Michael J Salata
- University Hospitals Sports Medicine Institute, Cleveland, Ohio, U.S.A
| | - James E Voos
- University Hospitals Sports Medicine Institute, Cleveland, Ohio, U.S.A
| | - Michael R Karns
- University Hospitals Sports Medicine Institute, Cleveland, Ohio, U.S.A
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Sherman B, Harrah T, Schlechter JA. Relaxation of the Medial Collateral Ligament to Facilitate Pediatric Meniscal Surgery. Arthrosc Tech 2019; 8:e1345-e1351. [PMID: 31890506 PMCID: PMC6926301 DOI: 10.1016/j.eats.2019.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/17/2019] [Indexed: 02/03/2023] Open
Abstract
Meniscal injuries are becoming increasingly common in the pediatric population. During arthroscopic evaluation, pediatric patients typically have pristine articular cartilage and tight medial joint spaces. Therefore, when an arthroscope enters the medial compartment, iatrogenic damage to the articular cartilage may occur. Additionally, proper visualization of the medial meniscus (posterior horn or meniscocapsular junction) can prove to be difficult, and potential pathology may be missed. Proposed methods of increasing medial compartment visualization include the use of a 70° arthroscope placed through the intercondylar notch (Gillquist maneuver), creation of a posteromedial portal, or relaxation of the deep medial collateral ligament (MCL). Similar techniques have been described for use in adults for partial meniscectomy, but not in the pediatric population. The purpose of this Technical Note is to describe the steps to successfully perform the relaxation technique for meniscal repairs in pediatric patients, using an extra-articular outside-in percutaneous method.
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Affiliation(s)
- Benjamin Sherman
- Riverside University Health System, Orange, California,Address correspondence to Benjamin Sherman, D.O., Riverside University Health System, Moreno Valley, CA 92555.
| | - Tanner Harrah
- Riverside University Health System, Orange, California
| | - John A. Schlechter
- Riverside University Health System, Orange, California,Moreno Valley, California, and the Children's Hospital of Orange County, Orange, California
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Said J, Frizzell K, Heimur J, Kachooei A, Beredjiklian P, Rivlin M. Visualization During Endoscopic Versus Open Cubital Tunnel Decompression: A Cadaveric Study. J Hand Surg Am 2019; 44:697.e1-697.e6. [PMID: 30420193 DOI: 10.1016/j.jhsa.2018.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 08/14/2018] [Accepted: 10/02/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the minimum incision size needed using an open cubital tunnel technique to obtain equivalent visualization comparable with an endoscopic technique. METHODS Visualization was assessed in 10 fresh-frozen cadavers with a 2-cm incision, using percutaneous needle localization with the endoscopic system. The most proximal and distal extent of the field of view was marked. Next, an open cubital tunnel release was performed on each cadaver specimen. The incision size was increased incrementally, and the most proximal and distal extents of visualization were recorded for each incision size. The mean visualization distance and standard deviation for each incisional length were calculated. RESULTS The mean proximal field of view with the endoscopic technique was 8.1 cm. The mean distal field of view was 8.3 cm. Using the open technique, a 2-cm incision allowed 5.9 cm visualization proximally and 5.2 cm distally, which was significantly less than the endoscopic view. A 4-cm open incision provided similar visualization as the endoscopic technique. A 6-cm open incision was required to obtain statistically significant improvements in visualization compared with an endoscopic technique. CONCLUSIONS A 4-cm open incision allowed visualization of approximately 9 cm proximal and 9 cm distal to the medial epicondyle, which was equivalent to the 2-cm endoscopic technique for cubital tunnel release. CLINICAL RELEVANCE Although the endoscopic release allows greater visualization of the ulnar nerve with a smaller incision, it is unclear whether this improvement in visualization improves the surgeon's ability to decompress the ulnar nerve.
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Affiliation(s)
- Joseph Said
- Department of Orthopaedic Surgery, Division of Hand Surgery, Rothman Institute, Jefferson Medical College, Philadelphia, PA
| | - Kaela Frizzell
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA
| | - Juliana Heimur
- Rowan University School of Osteopathic Medicine, Stratford, NJ
| | - Amir Kachooei
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Pedro Beredjiklian
- Department of Orthopaedic Surgery, Division of Hand Surgery, Rothman Institute, Jefferson Medical College, Philadelphia, PA
| | - Michael Rivlin
- Department of Orthopaedic Surgery, Division of Hand Surgery, Rothman Institute, Jefferson Medical College, Philadelphia, PA.
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The 45 degrees arthroscope: A forgotten scope in knee surgery. Orthop Traumatol Surg Res 2019; 105:691-695. [PMID: 30853456 DOI: 10.1016/j.otsr.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 02/07/2019] [Accepted: 02/11/2019] [Indexed: 02/02/2023]
Abstract
The majority of knee arthroscopic procedures are performed with 30° scope while the 70° arthroscope is mainly used for surgery of posterior compartments. In the arthroscopic armamentarium, another scope, unknown to many surgeons, is also available: the 45° arthroscope. His field of view provides a wider intraoperative view than that of a 30° scope without the characteristic blind spot of a 70° scope. Therefore, the surgeon's orientation is not compromised. because the optic has always an element of forward vision. With these advantages, the 45° scope can be used in all knee surgical procedures without the need for having two scopes sterilized on the surgical table with less risk of contamination and less surgical time. The 45° scope may also be valuable for the arthroscopic surgery of other joints with the same advantages.
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13
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The percutaneous pie-crusting medial release during arthroscopic procedures of the medial meniscus does neither affect valgus laxity nor clinical outcome. Knee Surg Sports Traumatol Arthrosc 2018; 26:2912-2919. [PMID: 29285587 DOI: 10.1007/s00167-017-4827-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To analyze the effect of percutaneous pie-crusting medial release on valgus laxity before and after surgery and on clinical outcomes. METHODS Eight-hundred fourteen consecutive patients who underwent an arthroscopic procedure for the medial compartment of the knee were evaluated retrospectively. Sex, age, type of operation (meniscectomy, meniscal repair, and posterior root repair), type of accompanying surgery (none, cartilage procedure, ligament procedure and osteotomy) were documented. Sixty-four patients who underwent percutaneous pie-crusting medial release (release group) and 64 who did not undergo medial release (non-release group) were matched using the propensity score method. Each patient was evaluated for the following variables: degree of valgus laxity on stress radiographs, Lysholm knee score, visual analog scale score, and International Knee Documentation Committee knee score and grade. RESULTS At the 24-month follow-up, no significant increase in side-to-side differences in the valgus gap was observed in comparison to the preoperative value in the release group [preoperative, - 0.1 ± 1.3 mm; follow-up, - 0.1 ± 1.4 mm; (n.s.)]. The follow-up Lysholm score, visual analog scale score and International Knee Documentation Committee knee score and grade were similar between the two groups. CONCLUSIONS Percutaneous pie-crusting medial release is an additional procedure that can be performed during arthroscopic surgery for patients with a narrow medial joint space of the knee. Percutaneous pie-crusting medial release reduces iatrogenic injury to the cartilage and does not produce any residual valgus laxity of the knee. LEVEL OF EVIDENCE IV.
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Di Vico G, Di Donato SL, Balato G, Correra G, D'Addona A, Maffulli N, Rosa D. Correlation between time from injury to surgery and the prevalence of ramp and hidden lesions during anterior cruciate ligament reconstruction. A new diagnostic algorithm. Muscles Ligaments Tendons J 2018; 7:491-497. [PMID: 29387643 DOI: 10.11138/mltj/2017.7.3.491] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Anterior cruciate ligament tears (ACL) are associated with meniscal lesions, that could involve the posterior horn of the medial meniscus (PHMM). A variety of techniques has been proposed to better visualise the postero-medial (PM) compartment. The aim of the study is to evaluate the prevalence of longitudinal tears of peripheral attachment of the PHMM during arthroscopic ACL reconstruction, and to describe a diagnostic algorithm. Methods 115 patients who underwent arthroscopic ACL reconstruction were enrolled for the study. An anterior and an intercondylar notch visualisation were ordinarily performed. A postero-medial (PM) portal was performed when the instability of the posterior horn was detected. Statistical significance was assessed by a Chi-squared or Fisher's Exact Test for categorical variables, and by a Mann-Whitney U test for continuous variables. Results We recorded a 9.6% prevalence of lesions of the peripheral attachment of PHMM. Nine ramp lesions and two hidden lesions were diagnosed. Patients treated within 6 months from injury, revealed a statistically significant correlation with a higher prevalence of these lesions. Conclusion Ramp and hidden lesions are very common ACL rupture associated injuries. Our diagnostic algorithm is a valid and safe option to diagnose these kinds of lesions. A correlation between a longer time from injury than 6 months and a reduced prevalence of these lesions was recorded in our population. Level of evidence IV.
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Affiliation(s)
| | - Sigismondo Luca Di Donato
- Orthopaedic Unit, Department of Public Health, School of Medicine, University of Naples Federico Il, Naples, Italy
| | - Giovanni Balato
- Orthopaedic Unit, Department of Public Health, School of Medicine, University of Naples Federico Il, Naples, Italy
| | - Gaetano Correra
- Orthopaedic Unit, Department of Public Health, School of Medicine, University of Naples Federico Il, Naples, Italy
| | - Alessio D'Addona
- Orthopaedic Unit, Department of Public Health, School of Medicine, University of Naples Federico Il, Naples, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy; Centre for Sports and Exercise Medicine, Mile End Hospital, Barts and The London School of Medicine and Dentistry, London, UK
| | - Donato Rosa
- Orthopaedic Unit, Department of Public Health, School of Medicine, University of Naples Federico Il, Naples, Italy
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Cuéllar A, Cuéllar A, Sánchez A, Cuéllar R. Posterior Lateral Meniscus Root Reattachment With Suture Anchors: An Arthroscopic Technique. Arthrosc Tech 2017; 6:e1919-e1925. [PMID: 29416979 PMCID: PMC5797299 DOI: 10.1016/j.eats.2017.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/11/2017] [Indexed: 02/03/2023] Open
Abstract
The posterior lateral meniscus root (PLMR) provides the circumferential tension required to stabilize the lateral meniscus. Thus, preservation of the PLMR is important to prevent an increase in tibiofemoral contact pressure, which could result in osteoarthritis. We describe an all-arthroscopic approach to the fixation of PLMR using suture anchors through associated posterolateral arthroscopic portals that result in a more favorable inclination of the anchors. Initially, the anatomical insertion site of the root on the tibial plateau is debrided, 1 to 2 anchors are placed through the posterolateral portals into the root's footprint area, and the meniscus is finally sutured from the posterolateral portals. Compression of the meniscus is achieved with bone contact. This technique achieves lateral meniscus root fixation, reducing the risk of subluxation of the meniscus and subsequent osteoarthritis.
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Affiliation(s)
- Adrián Cuéllar
- Department of Traumatology and Orthopaedic Surgery of the Galdakao-Usansolo Hospital, Galdácano, Spain,Address correspondence to Adrián Cuéllar, M.D., Department of Traumatology and Orthopaedic Surgery, Galdakao Hospital, University of Basque Country, c./Labeaga, s/n, Usansolo, Vizcaya 48960, Spain.Department of Traumatology and Orthopaedic SurgeryGaldakao HospitalUniversity of Basque Countryc./Labeaga, s/nUsansoloVizcaya48960Spain
| | - Asier Cuéllar
- Department of Traumatology and Orthopaedic Surgery of the Donostia Universitary Hospital, San Sebastián, Spain
| | - Alberto Sánchez
- Department of Traumatology and Orthopaedic Surgery of the Galdakao-Usansolo Hospital, Galdácano, Spain
| | - Ricardo Cuéllar
- Department of Traumatology and Orthopaedic Surgery of the Donostia Universitary Hospital, San Sebastián, Spain
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Kekatpure AL, Adikrishna A, Sun JH, Sim GB, Chun JM, Jeon IH. Comparative analysis of visual field and image distortion in 30° and 70° arthroscopes. Knee Surg Sports Traumatol Arthrosc 2016; 24:2359-64. [PMID: 25423874 DOI: 10.1007/s00167-014-3452-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 11/18/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE There have been very few attempts to compare the visual fields and image distortion in arthroscopes. To better understand the images generated using existing arthroscopes, we performed image-mapping experiments to assess field of view and image distortion. The purpose of this study was to quantify and compare the visual fields obtained using 30° and 70° arthroscopes and assess image distortion in each arthroscope. METHODS A complete arthroscopy system was used in this study. To perform this quantitative analysis, we created a customized measurement device that consisted of three parts: (1) distance marker, (2) chessboard pattern, and (3) angle marker. Three observers collectively assessed the appropriate position of the arthroscope during simulation. For each scope, ten simulations were performed at distances between 1 and 3 cm. Using the obtained arthroscope images, field of view and image distortion were measured and calculated. RESULTS The field of view of the 70° arthroscope was 5, 10, and 15 mm wider in diameter in comparison with the 30° arthroscope at 1, 2, and 3 cm, respectively. Moreover, the 70° arthroscope had less 0.66, 0.13, and 0.26 pixels of root-mean-square distance than the 30° arthroscope at 1, 2, and 3 cm, respectively. The 70° arthroscope also contained 0.78 pixels less at the maximal error than the average 30° arthroscope. Therefore, the 70° arthroscope demonstrated less distortion than the 30° arthroscope. There was no significant difference between the two scopes with respect to median curvature measurement at 1-cm distance. CONCLUSION The 70° arthroscope demonstrates technical advantages over the 30° arthroscope, including a wider field of view and a less image distortion at the periphery. A wide angle and less image distortion can help better orient the surgeon within the joint cavity when a panoramic picture is needed to repair rotator cuff tears, in case of hip arthroscopy, or while treating the lesions of posterior horn of medial meniscus.
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Affiliation(s)
- Aashay L Kekatpure
- Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Arnold Adikrishna
- Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Ji-Ho Sun
- Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Gyeong-Bo Sim
- Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Jae-Myung Chun
- Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea
| | - In-Ho Jeon
- Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea.
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Calvisi V, Zoccali C. Arthroscopic patterns of the poster-medial aspect of the knee joint: classification of the gastrocnemius-semimembranosus gateway and its relationship with Baker's cyst. Muscles Ligaments Tendons J 2016; 6:492-498. [PMID: 28217572 DOI: 10.11138/mltj/2016.6.4.492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The gastrocnemius-semimembranosus bursa may communicate with the knee joint. The arthroscopic anatomy of the posteromedial aspect varies depending on the angle of the oblique popliteal ligament, the level at which it crosses the medial gastrocnemius tendon, and its relationship with the capsular joint and synovia. The aim of this paper is to identify possible patterns, and to evaluate their characteristics and their relationship with Baker's cyst. METHODS data archived from 185 consecutive arthroscopies were evaluated; an anatomic description and classification was carried out; the percentages of association with BC and the associated pathologies were reported. RESULTS The different anatomies were classified into six groups based on the relationship above the medial gastrocnemius tendon, the capsular joint and synovia. The prevalence of Baker's cyst was 28.3%. The main associated intra-articular pathological condition was the contemporary presence of a meniscal tear and chondropathy. CONCLUSION Exploration of the posterior aspect of the knee must be performed routinely. Knowing the possible anatomy patterns of the posteromedial arthroscopic aspect of the knee joint could help to identify the cyst and its gateway, thus facilitating its treatment. LEVEL OF THE EVIDENCE III.
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Affiliation(s)
- Vittorio Calvisi
- Department of Orthopaedic and Traumatology School, University of L'Aquila, Italy
| | - Carmine Zoccali
- Regina Elena National Cancer Institute, Oncological Orthopedic Department, Rome, Italy
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Ohishi T, Takahashi M, Suzuki D, Matsuyama Y. Arthroscopic approach to the posterior compartment of the knee using a posterior transseptal portal. World J Orthop 2015; 6:505-512. [PMID: 26301179 PMCID: PMC4539473 DOI: 10.5312/wjo.v6.i7.505] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/27/2015] [Accepted: 06/19/2015] [Indexed: 02/06/2023] Open
Abstract
Arthroscopic surgery of the posterior compartment of the knee is difficult when only two anterior portals are used for access because of the inaccessibility of the back of the knee. Since its introduction, the posterior transseptal portal has been widely employed to access lesions in the posterior compartment. However, special care should be taken to avoid neurovascular injuries around the posteromedial, posterolateral, and transseptal portals. Most importantly, popliteal vessel injury should be avoided when creating and using the transseptal portal during surgery. Purpose of the present study is to describe how to avoid the neurovascular injuries during establishing the posterior three portals and to introduce our safer technique to create the transseptal portal. To date, we have performed arthroscopic surgeries via the transseptal portal in the posterior compartments of 161 knees and have not encountered nerve or vascular injury. In our procedure, the posterior septum is perforated with a 1.5-3.0-mm Kirschner wire that is protected by a sheath inserted from the posterolateral portal and monitored from the posteromedial portal to avoid popliteal vessel injury.
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19
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Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX, Seil R. Hidden lesions of the posterior horn of the medial meniscus: a systematic arthroscopic exploration of the concealed portion of the knee. Am J Sports Med 2014; 42:921-6. [PMID: 24567252 DOI: 10.1177/0363546514522394] [Citation(s) in RCA: 204] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears are frequently associated with meniscal lesions. Despite improvements in meniscal repair techniques, failure rates remain significant, especially for the posterior horn of the medial meniscus. PURPOSE To determine whether a systematic arthroscopic exploration of the posterior horn of the medial meniscus with an additional posteromedial portal is useful to identify otherwise unrecognized lesions. STUDY DESIGN Case series; Level of evidence, 4. METHODS In a consecutive series of 302 ACL reconstructions, a systematic arthroscopic exploration of the posterior horn of the medial meniscus was performed. The first stage of the exploration was achieved through anterior visualization via a standard anterolateral portal. In the second stage, the posterior horn of the medial meniscus was visualized posteriorly via the anterolateral portal with the scope positioned deep in the notch. In the third stage, the posterior horn was probed through an additional posteromedial portal. A χ2 test and logistic regression analysis were performed to determine if the time from injury to surgery was associated with the meniscal tear pattern. RESULTS A medial meniscal tear was diagnosed in 125 of the 302 patients (41.4%). Seventy-five lesions (60%) located in the meniscal body were diagnosed at the first stage of the arthroscopic exploration. Fifty lesions located in the ramp area were diagnosed: 29 (23.2%) at the second stage and 21 lesions (16.8%) at the third stage after minimal debridement of the superficial soft tissue layer. The latter type of lesion is called a "hidden lesion." Altogether, the prevalence of ramp lesions in this population was 40%. Meniscal body lesions (odds ratio, 2.6; 95% confidence interval, 1.18-5.18; P < .02) were found to be significantly correlated with a longer delay between injury and surgery. CONCLUSION Posterior visualization and posteromedial probing of the posterior horn of the medial meniscus can help in discovering a higher rate of lesions that could be easily missed through a standard anterior exploration. In numerous cases, these lesions were "hidden" under a membrane-like tissue and were discovered after minimal debridement through a posteromedial portal.
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Affiliation(s)
- Bertrand Sonnery-Cottet
- Bertrand Sonnery-Cottet, Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008 Lyon, France.
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Fakioglu O, Ozsoy MH, Ozdemir HM, Yigit H, Cavusoglu AT, Lobenhoffer P. Percutaneous medial collateral ligament release in arthroscopic medial meniscectomy in tight knees. Knee Surg Sports Traumatol Arthrosc 2013; 21:1540-5. [PMID: 22766688 DOI: 10.1007/s00167-012-2128-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 06/21/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Visualization and surgery of tears in the posterior medial meniscus are difficult in tight knees. Iatrogenic chondral lesions might cause serious morbidity, and residual tears may result in inadequate symptom relief. We evaluated the clinical and radiological results of superficial medial collateral ligament (MCL) release during arthroscopic medial meniscectomy in tight knees. METHODS Eighteen patients [median age: 43 years (22-59); median follow-up: 8.3 months (6-12)] who underwent arthroscopic meniscectomy were included in the study. Patients with ligamentous injuries, severe chondral damage or meniscal repairs were excluded. Preoperatively, anteroposterior knee radiographs were obtained with 11-kg valgus stress using a specialized instrument. During the operation, if opening of the medial knee in 30° flexion under 11-kg valgus stress was inadequate, controlled release of the posterior portion of the MCL was performed using a 16-gauge needle. Intraoperative valgus stress was monitored using a specially designed lateral support with mounted load cell. MCL injury was evaluated both with magnetic resonance imaging (MRI) and valgus stress radiographs, which were obtained in the 1st week and 3rd and 6th months postoperatively to monitor healing of the elongated MCL. RESULTS In all patients, meniscectomy could be performed with adequate visualization of the posterior medial meniscus and without iatrogenic chondral injury. The median medial joint space width on valgus stress radiographs was 7.1 mm preoperatively and 9.1, 8.0 and 7.2 mm in the 1st week, and 3rd and 6th months, respectively (p < 0.0001). On MRI, the injured structure was the posterior two-thirds of the MCL. Median Lysholm score, which was 42 points before the operation, had increased to 94 points at the final follow-up (p = 0.0002). CONCLUSION Controlled release of the MCL in tight knees allowed easier handling in posterior medial meniscus tears and a better understanding of tear configurations, avoiding iatrogenic chondral lesions. The MCL injury healed uneventfully. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Onur Fakioglu
- Department of Orthopaedics and Traumatology, Dortyol State Hospital, Hatay, Turkey
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Jones C, Reddy S, Ma CB. Repair of the posterior root of the medial meniscus. Knee 2010; 17:77-80. [PMID: 19740665 DOI: 10.1016/j.knee.2009.06.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 06/13/2009] [Accepted: 06/23/2009] [Indexed: 02/02/2023]
Abstract
Tears of the posterior root of the medial meniscus are becoming increasingly recognized. Early identification and treatment of these tears help halt the progression of cartilage degeneration and osteoarthritis of the knee. Repair of these tears is essential for recreating the hoop stress of the medial meniscus. In this note, we describe a successful arthroscopic technique to repair this lesion. A posteromedial portal is established by which two 2-0 PDS sutures are placed through the meniscus root and pulled down through a trans-tibial tunnel and fixed using an EndoButton distally along the anterolateral cortex of the tibia. This has been performed successfully in five patients with no complications.
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Shaver JC, Johnson DL. Unlocking the 'pivot shift' in ACL surgery: medial meniscus evaluation and treatment. Orthopedics 2008; 31:orthopedics.34714. [PMID: 19226063 DOI: 10.3928/01477447-20081201-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Meniscal injury commonly occurs in conjunction with anterior cruciate ligament (ACL) disruption. Failure to recognize and treat these injuries may lead to less than ideal outcomes in ACL reconstruction. With their unique anatomical location, often at the peripheral rim of the posterior horn of the medial meniscus, the instability pattern of ACL deficiency may contribute to failure of injury recognition. Standard anterior viewing portals do not allow adequate visualization of a large portion of the posterior horn of the medial meniscus. Alternative viewing techniques, such as an accessory posteromedial arthroscopy portal or the Gillquist maneuver, may improve visualization of the posteromedial compartment, but require additional surgery and/or equipment. The pattern of instability inherent to ACL deficiency, or the "pivot shift," occurs when the surgeon attempts to visualize the posteromedial compartment with full extension of the knee and a valgus load. The knee "pivots" as the lateral tibial plateau anteriorly subluxes and rotates around the tibial spines. This rotation and subluxation closes down the posteromedial compartment and blocks visualization. A simple maneuver helps to eliminate this pathologic motion, or "unlock the pivot." During attempted visualization of the medial meniscus, the leg is held in mild flexion (207) with a valgus moment on the knee. While this position is held, the surgical assistant externally rotates the lower leg about the knee axis as the knee is extended and valgus is applied. This maneuver increases the surgeon's viewing area of the posteromedial compartment, which may decrease the need for accessory portals and additional equipment in the ACL deficient knee.
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Affiliation(s)
- J Christopher Shaver
- Department of Sports Medicine, K431 Kentucky Clinic 0284, 740 S Limestone St, Lexington, KY 40536, USA
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The fate of patellar tendon and infrapatellar fat pad after arthroscopy via central portal. Knee Surg Sports Traumatol Arthrosc 2008; 16:1114-20. [PMID: 18779950 DOI: 10.1007/s00167-008-0612-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Accepted: 08/18/2008] [Indexed: 10/21/2022]
Abstract
Central patellar (CP) portal is an accessory portal in arthroscopic knee surgery, which generally is considered to be safe. In this cross sectional study, we aimed to delineate the clinical and radiological outcome of patellar tendon (PT) and Hoffa's fat pad after the use of this approach. From our hospital records, patients who underwent arthroscopy via CP portal were identified and were invited for the study. There were16 men and 4 women with a mean age of 32 years. Mean follow-up time was 28 months. Meniscectomy had been performed for irreparable bucket-handle type medial meniscal tears in all patients. At the latest follow-up, no patients had anterior knee pain and physical examination was normal. Mean PT thickness of operated knees measured with Ultrasonography was 5.63+/-1.56, while it was 3.76+/-0.46 mm in contralateral knees and the difference was significant. Contour irregularity of PT and focal hypoechoic areas were found in 17 patients, two of which also had hyperechogenic calcification focuses. Abnormal signal intensity of PT was also found in 17 patients with Magnetic Resonance Imaging (MRI). Eleven of these had decreased signal intensity within the tendon which was interpreted as fibrosis. In six patients, increased signal intensity, radiologically similar to chronic tendinitis, was detected. Four patients had decreased signal intensity in the Hoffa's fat pad. Local fibrous tissues in patellar tendon might cause weakness in the tendon. This study showed that although CP portal did not cause any clinical problems in a low demand group of patients, it leads to a significant radiological sequela in the tendon, biomechanical significance of which needs to be clarified.
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Naranje S, Mittal R, Nag H, Sharma R. Arthroscopic and magnetic resonance imaging evaluation of meniscus lesions in the chronic anterior cruciate ligament-deficient knee. Arthroscopy 2008; 24:1045-51. [PMID: 18760213 DOI: 10.1016/j.arthro.2008.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Revised: 03/10/2008] [Accepted: 03/24/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE We performed this prospective study to evaluate the incidence of meniscus tears arthroscopically and the effectiveness of magnetic resonance imaging (MRI) in detecting these lesions in patients with chronic anterior cruciate ligament (ACL)-deficient knees. METHODS We reviewed 50 patients (46 male and 4 female) with a mean age of 27 years (range, 18 to 48 years) who underwent ACL reconstruction for chronic ACL tears. Injuries were classified as chronic because arthroscopy was performed after more than 6 weeks of injury. All 50 patients had clinical and MRI evaluation followed by knee arthroscopy. The MRI and arthroscopic findings were then analyzed by a single independent reviewer. The presence of meniscus tears and their morphologic types and locations were analyzed. The sensitivity, specificity, positive predictive value, and negative predictive value of MRI were calculated. RESULTS On arthroscopy, a medial meniscus tear was found in 18 patients (36%), a lateral meniscus tear was found in 11 patients (22%), both menisci were torn in 8 patients (16%), and no meniscus lesion was found in 13 patients (26%). The most common morphologic type of tear seen in the medial meniscus was "complex" (n = 11 [42%]), and that in the lateral meniscus was "longitudinal" (n = 10 [53%]). The posterior horn of the meniscus was the most common tear site. The overall sensitivity, specificity, positive predictive value, and negative predictive value for detecting meniscus tears in chronic ACL-deficient knees on MRI were 90%, 89%, 87%, 93%, respectively. CONCLUSIONS We conclude from our study that in chronic ACL-deficient patients, the prevalence of posterior horn medial meniscus tears seems to be high. Anterior horn tears and radial and horizontal patterns of meniscus tears seem to be rare in chronic ACL deficiency. MRI correlates well with arthroscopy and has high negative predictive values. LEVEL OF EVIDENCE Level I, prognostic prospective study.
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Affiliation(s)
- Sameer Naranje
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Ahn JH, Lee DH, Lee YS, Wang JH, Ha HC. Clearing a blind spot in knee arthroscopy: popliteal bursa. Knee Surg Sports Traumatol Arthrosc 2008; 16:549-52. [PMID: 18365180 DOI: 10.1007/s00167-008-0488-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Accepted: 01/09/2008] [Indexed: 11/28/2022]
Abstract
Each arthroscopic portal to the knee has a blind area that cannot be inspected directly. In particular, visualization of the posterior compartment is difficult to access. Although arthroscopic procedures for the posterior compartment of the knee joint have been developed through posteromedial, posterolateral and posterior trans-septal portal, the popliteal bursa remains as an area that is difficult to access and manipulate. We report a surgical procedure that can examine one of the blind spots in knee arthroscopy, popliteal bursa.
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Affiliation(s)
- Jin-Hwan Ahn
- Department of Orthopedic Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, South Korea
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Ahn JH, Yoo JC, Lee SH. Arthroscopic loose-body removal in posterior compartment of the knee joint: a technical note. Knee Surg Sports Traumatol Arthrosc 2007; 15:100-6. [PMID: 16972108 DOI: 10.1007/s00167-006-0098-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Accepted: 11/25/2005] [Indexed: 01/15/2023]
Abstract
The arthroscopic removal of loose bodies in the knee joints is a relatively common procedure. Quite often intra-articular loose bodies tend to localize at the posterior compartment due to gravity effect. However, it is often technically demanding to find and remove loose bodies located at the posterior compartment of the knee joint arthroscopically. We present the technical aspects of arthroscopic removal of the loose bodies located in the posterior compartment of the knee joint. Loose bodies at posterior compartment were subdivided into six regions in posterior knee compartment with preoperative MRI and arthroscopic findings. Each section needs slight different application of arthroscopic techniques for removal. We retrospectively studied 52 knees in 50 patients who underwent arthroscopic loose-body removal in posterior compartment, in 28 knees, additional posterior trans-septal portal was needed for removal of loose bodies. With the help of trans-septal portal, we have successfully removed the loose bodies even from the most difficult locations in posterior compartment.
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Affiliation(s)
- Jin Hwan Ahn
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-ku, Seoul 135-710, Korea
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Kramer DE, Bahk MS, Cascio BM, Cosgarea AJ. Posterior knee arthroscopy: anatomy, technique, application. J Bone Joint Surg Am 2006; 88 Suppl 4:110-21. [PMID: 17142441 DOI: 10.2106/jbjs.f.00607] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Dennis E Kramer
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 601 North Caroline Street, Baltimore, MD 21287, USA.
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Eckhardt BP, Hernandez RJ. Pigmented villonodular synovitis: MR imaging in pediatric patients. Pediatr Radiol 2004; 34:943-7. [PMID: 15448943 DOI: 10.1007/s00247-004-1261-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2004] [Revised: 06/03/2004] [Accepted: 06/07/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To describe the usefulness of gradient-echo imaging and contrast-enhanced MR imaging in diagnosing and assessing the extent of pigmented villonodular synovitis (PVNS) in pediatric patients. PATIENTS AND METHODS Retrospective analysis of five pediatric patients (median age 14 years) with PVNS of the knee examined with a 1.5-T unit. Signal characteristics were obtained comparing T1- and proton-density (PD)-weighted imaging with gradient-echo imaging and enhanced imaging. The extent of the disease was assessed using the arthroscopic approach. Signal intensity ratios were statistically analyzed. RESULTS Compared to PD- and T1-weighted imaging sequences, gradient-echo imaging provides superior depiction of the extent of the disease due to signal decay (T2*-effect) of hemosiderin-laden thickened synovium and masses. Inflamed synovium with low hemosiderin deposition was identified on enhanced imaging. Beside the suprapatellar bursa and Hoffa's fat pad, the area posterior to the cruciate ligaments is commonly involved. No bony abnormalities were present. CONCLUSION Gradient-echo imaging together with enhanced imaging is useful in diagnosing and assessing the extent of PVNS in pediatric patients. A low signal mass behind the cruciate ligaments may represent an important diagnostic feature. Bony abnormalities were always absent.
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Affiliation(s)
- Boris P Eckhardt
- Department of Radiology, C. S. Mott Children's Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0252, USA.
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Abstract
PURPOSE The purpose of this study was to introduce clinical features and characteristics of radial tears of the posterior horn of the medial meniscus and the results of arthroscopic surgery. TYPE OF STUDY Retrospective case series. METHODS From August 1996 to December 1999, 345 consecutive cases of medial meniscal tears were treated using arthroscopic surgery in Asan Medical Center, Seoul, Korea. Of these, 96 cases (27.8%) with radial tears of the posterior horn of the medial meniscus were reviewed. All patients were treated with arthroscopic partial meniscectomy. Based on medical records, including surgical notes and detailed arthroscopic photographs, we reviewed the age distribution of the patients, preoperative physical signs, magnetic resonance imaging, surgical findings, and clinical results using the Lysholm Knee Scoring scale and our own questionnaire. RESULTS Radial tears of the posterior horn of the medial meniscus were more common than previously known and also were more common in elderly patients. Most patients presented mechanical symptoms. Magnetic resonance imaging often failed to reveal the tears. Careful attention to the nature of pain and the physical examination was critical in making a diagnosis. Although most patients were elderly and had degenerated articular cartilages, subjective symptoms improved significantly after arthroscopic partial meniscectomy. CONCLUSIONS Radial tears of the medial meniscus posterior horn are common. Diagnosis of this tear is often difficult because most patients have osteoarthritic knees masking meniscal tears and magnetic resonance imaging shows unacceptably high rates of false-negative results. Following strict surgical indications, arthroscopic partial meniscectomy can help patients with low morbidity. LEVEL OF EVIDENCE Level IV therapeutic study (case series, no or historical control group).
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Affiliation(s)
- Seong-Il Bin
- Department of Orthopaedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea.
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Yip DKH, Wong JWK, Chien EP. Arthroscopic surgery in the posterior compartment of the knee: Suture fixation of anterior and posterior cruciate ligament avulsions. Arthroscopy 2003; 19:23E. [PMID: 12627140 DOI: 10.1053/jars.2003.50074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Anterior and posterior cruciate ligament avulsion injuries in the posterior compartment of the knee are most commonly dealt with using open approaches. We report an arthroscopic method of treatment using sutures, without the need of any metal implants, that can be safely used in patients with open physes and without the need of a 70 degrees arthroscope.
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Affiliation(s)
- Daniel K H Yip
- Department of Orthopaedic Surgery, University of Hong Kong
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Rotura de menisco. Errores diagnósticos en RM. RADIOLOGIA 2003. [DOI: 10.1016/s0033-8338(03)77846-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
The authors introduce a safe arthroscopic technique of making a portal through the posterior septum of the knee joint, posterior to the posterior cruciate ligament (PCL). This posterior trans-septal portal makes it possible for the arthroscope or the working instruments inserted through the posteromedial portal to reach the posterolateral compartment. With this portal, complete arthroscopic visualization of the posterior compartment and easier arthroscopic procedures for the posterior compartment of the knee joints are possible, including the posterior and posterosuperior aspect of the both femoral condyles, the posterior horns of both menisci, the posterior and inferior portion of the PCL, the posterior meniscofemoral ligament, the posterior septum, and the posterior capsule. We have used this technique in more than 150 knees for arthroscopic total synovectomy for arthritis of various origins, arthroscopic PCL reconstructions, arthroscopic removal of encapsulated loose bodies or tumors located behind the PCL, arthroscopic repairs of tears in the posterior horns of the medial menisci using the all-inside technique, arthroscopic pullout suture fixation of the avulsion fracture of tibial attachment of PCL, and others. No complications such as injuries of the popliteal neurovascular structures have occurred in our experience.
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Affiliation(s)
- J H Ahn
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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35
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Abstract
Meniscal surgery is one of the most common orthopedic procedures performed today. Orthopedic surgeons must be familiar with the indications for meniscal excision versus repair and comfortable with the diverse instrumentation used for both techniques. Numerous pitfalls exist in diagnosis, indication, and technical aspects of surgery but can be minimized or avoided by careful preoperative planning and attention to detail during the surgical procedure.
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Affiliation(s)
- A A Kale
- Department of Orthopaedic Surgery, University of Southern California School of Medicine, Los Angeles, USA
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Kaplan PA, Gehl RH, Dussault RG, Anderson MW, Diduch DR. Bone contusions of the posterior lip of the medial tibial plateau (contrecoup injury) and associated internal derangements of the knee at MR imaging. Radiology 1999; 211:747-53. [PMID: 10352601 DOI: 10.1148/radiology.211.3.r99jn30747] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine if there are any predictable patterns of internal derangement associated with a bone contusion of the posterior lip of the medial tibial plateau at magnetic resonance (MR) imaging and to offer a biomechanical explanation for the findings. MATERIALS AND METHODS A retrospective review of 215 consecutive MR examinations for knee trauma was conducted to identify contusions of the posterior lip of the medial tibial plateau. Any additional contusions and internal derangements were documented in the cases with these contusions. Medical charts and arthroscopic results, when available, were reviewed for mechanisms of injury. RESULTS The specific medial tibial contusion was demonstrated in 25 of 215 (12%) knee MR examinations. Associated anterior cruciate ligament (ACL) tears were found in 25 of the 25 (100%) examinations. Injury to the meniscocapsular junction (14 of 25) or a peripheral tear of the posterior horn of the medial meniscus (10 of 25) occurred in a combined 96% of the cases. Lateral compartment contusions were noted in 24 (96%) cases. Pivot, twisting, or valgus forces were reported mechanisms of injury. CONCLUSION Contusions involving the posterior lip of the medial tibial plateau may result from a contrecoup impaction injury directly following an ACL tear, as the knee reduces. These contusions are almost always associated with a far peripheral meniscal tear or with a meniscocapsular junction injury affecting the posterior horn of the medial meniscus.
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Affiliation(s)
- P A Kaplan
- Department of Radiology, University of Virginia Health System, Charlottesville 22908, USA
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Abstract
Knee injuries continue to be an increasingly common and highly visible problem presenting to the sports medicine physician. The physicians who handle knee injuries will be challenged by patients, coaches, trainers, business agents, the press, and family members with an ever-increasing sophistication of medical knowledge. An understanding of the underlying structure and function of the commonly injured ligaments, menisci, and the patellofemoral joint is discussed. Diagnosis by physical examination is encouraged. Conservative and surgical treatment options are reviewed as are the considerations involved in deciding the time to return to sports.
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Affiliation(s)
- P D Fadale
- Department of Orthopaedic Surgery, Brown University School of Medicine, Rhode Island Hospital, Providence, USA
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Bernstein J. The diagnosis of meniscal tears in athletes. A comparison of clinical and magnetic resonance imaging investigations. Am J Sports Med 1997; 25:588-9. [PMID: 9240999 DOI: 10.1177/036354659702500430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Abstract
To perform surgery in the inaccessible area of the posterior compartment of the knee joint with the conventional anterior-posterior triangulation technique, we have used a direct posteromedial-posterolateral triangulation technique. This technique has been easy and safe in performing arthroscopic surgery in the posterior compartment, including synovectomy of 350 knees and removal of loose bodies in 12 knees. Using this method in addition to conventional anterior-posterior triangulation, the whole area of the posterior compartment could be covered for performing arthroscopic surgery.
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Affiliation(s)
- J M Kim
- Department of Orthopaedic Surgery, Kang-Nam St. Mary's Hospital, Catholic University Medical College, Seoul, Korea
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Abstract
Meniscal tears are common sports injuries. This article details the clinical evaluation of the athlete presenting with knee pain. Conservative (nonoperative) treatment and arthroscopic procedures are discussed.
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Affiliation(s)
- K E DeHaven
- Department of Orthopaedics, University of Rochester, New York, USA
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Rubin DA. MR IMAGING OF THE KNEE MENISCI. Radiol Clin North Am 1997. [DOI: 10.1016/s0033-8389(22)00577-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Gold DL, Schaner PJ, Sapega AA. The posteromedial portal in knee arthroscopy: an analysis of diagnostic and surgical utility. Arthroscopy 1995; 11:139-45. [PMID: 7794424 DOI: 10.1016/0749-8063(95)90058-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- D L Gold
- University of Pennsylvania, Sports Medicine Center, Philadelphia 19104, USA
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Abstract
Posterolateral and posteromedial portals are necessary for certain arthroscopic procedures of the knee. Many surgeons hesitate to use portals. A cadaveric study was performed to identify the structures at risk in establishing these portals. These include the saphenous vein and nerve, popliteal vessels, lateral superior and inferior genicular arteries, and peroneal nerve. Two basic techniques can be used to visualize the posterior compartments--from the same side or diagonally across the intracondylar notch. A clinical review of 179 patients in which posterior portals were used showed no serious complications. In three cases there was residual numbness in the distribution of the saphenous nerve and in two cases the saphenous vein was punctured. In three cases, the posterior compartments could not be safely visualized. In 87 cases the posterior compartment was visualized from the ipsilateral side; in the remaining 92 cases we used the contralateral technique placing the arthroscope diagonally across the intracondylar notch.
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