The clinical diagnosis of meniscal tear is not easy. Reliability of two clinical meniscal tests and magnetic resonance imaging.

AIM: to clarify the reliability of two clinical meniscal tests, McMurray's and Apley's and the MRI imaging, in order to establish how to reduce unjustified arthroscopies. METHODS: 102 patients were selected out of 160. All patients were submitted to a triple clinical examination (by a young surgeon and two skilled surgeons), MRI and an arthroscopic procedure. The investigated clinical tests were McMurray's and Apley's test. The positivity or negativity of the tests and MRI were compared to arthroscopic findings. Arthroscopy is considered the gold standard for the diagnosis of meniscal lesions. We measured the length of the meniscal lesions in order to correlate it to the clinical findings. RESULTS: From the clinical examination, we got the following data: McMurray's test: sensitivity 79.7%, specificity 78.5%, accuracy 79.4%, positive likelihood ratio 3.7, negative likelihood ratio 0.2. Apley's test: sensitivity 83.7%, specificity 71.4%, accuracy 80.3%, positive likelihood ratio 2.9, negative likelihood ratio 0.2. The composite assessment is strictly dependent on how the discordance of the two tests is evaluated. The assessment of the clinical tests was done even in relation to medial or lateral meniscal lesion. No statistical difference was found about the length of the meniscal tear. MRI gave the following results: sensitivity 78.3%, specificity 85.7%, accuracy 80.3%. CONCLUSIONS: If we use, as diagnostic means, McMurray's and Apley's clinical tests and MRI as imaging procedure, we have an accuracy of about 80%. It is important to keep in mind that it is not possible to have the absolute certainty of make a correct diagnosis in case of meniscal lesions. Patients, too, have to be informed about the risk of a negative arthroscopy.

Surgical management of chronic, unreduced posterior dislocation of the shoulder.

Four patients with chronic posterior dislocation of the shoulder underwent surgical treatment after an average delay of 10 months from injury. They were examined clinically and radiographically at an average follow-up of 32 months. Treatment consisted of subscapularis tendon transfer (McLaughlin procedure) into the humeral defect in one case, transfer of the lesser tuberosity (McLaughlin modified procedure) in two cases, and in the fourth case-a patient with a 19-month missed dislocation and 50% humeral head lesion-a transposition of the coracoid process and conjoined tendon was performed. X-rays and CT scan excluded avascular necrosis or severe post-traumatic arthrosis. All patients achieved complete pain relief without limitation of daily or work activities. A slight limitation of anterior elevation and external rotation was present in all patients. Our results confirm that McLaughlin's original or modified procedure is suggested in cases of chronic, unreduced posterior dislocation of the shoulder (type I according to Randelli). The transposition of the coracoid process is a valid alternative to prosthesis and to autologous or homologous bone graft implants.

Tibial intercondylar eminence fractures in adults: arthroscopic treatment.

Results obtained from the surgical treatment of 15 cases of type II and III tibial intercondylar eminence fractures-according to the classification of Meyers and McKeever [12, 13]-are reported in this paper. The average age of the patients observed was 22 years (range 18-41). All patients underwent an arthroscopic procedure of reduction and fixation. We used a bioabsorbable suture in ten patients and a nonabsorbable suture in five patients. The suture was passed at the ACL insertion, then pulled out through drilled tunnels and tied onto the anterior surface of the tibial metaphysis. Two of the 15 patients treated underwent an additional arthroscopic procedure because of arthrofibrosis, 2 months after the first surgical intervention. All patients were examined clinically and radiographically with an average follow-up of 18 months. According to the IKDC scoring system, recovery of the 13 patients not undergoing additional intervention was graded as normal or near normal. In 14 patients, anterior laxity was inferior to 5 mm at the KT-1000 arthrometer evaluation. Absorbable or nonabsorbable suture fixation is effective for obtaining a secure fixation and achieves good clinical and functional mid-term results.

Results of autologous osteochondral grafts in chondral lesions of the knee.

BACKGROUND: To evaluate multiple osteochondral autografts for the treatment of traumatic chondral lesions of the knee. METHODS: Twenty-four (19 male and 5 female) patients underwent multiple osteochondral transplantation from 1995 to1999, the age ranging from 19 and 47 years old. Osteochondral lesion was localized on the femoral condyle in 21 cases, on the patella in 1 case and on the femoral groove in other 2 cases. The size of the lesion varied from 1 cm2 to 3 cm2. In 7 cases a single osteochondral graft and in 14 multiple ostechondral grafts has been harvested from non weight bearing areas of the knee. All patients except four were operated by arthroscopy. Four patients underwent arthrotomy because of the location of the lesion. The patients were examined with a 1 and 3 month follow-up and yearly thereafter (average f.u. 2 years and 4 months). For the clinical evaluation we used the IKDC Subjective Knee Evaluation Form. Before surgery, and, thereafter, during the follow-up sessions, the circumference of the thigh 10 cm proximally to the superior apex of the patella was measured. RESULTS: The results were evaluated as satisfactory in 75% of the cases (18/24). Best results were obtained in isolated chondral lesions and in cases that requested a smaller number of grafts. All the patients had an excellent recovery of the ROM, while a 1.3 cm side to side difference of muscle trophism (thigh circumference) was present during the one year follow-up. CONCLUSIONS: We report good results with multiple autologous osteochondral grafts. Multiple osteochondral grafts appears to be the "Golden standard", in the treatment of chondral lesions lesions between 1.5 and 3.5 cm2.

Porosity-graded hydroxyapatite ceramics to replace natural bone.

Porous hydroxyapatite HA bodies were prepared with an aim to simulate bone tissue morphology. By varying the characteristics of starting HA powders and the impregnation strategy of cellulosic sponges with rheologically optimized slurries, a wide range of physico-chemical and mechanical properties of the porous ceramics can be obtained. The samples were characterized microstructurally, by density and porosimetry and by mechanical strength. Cylindrical specimens exhibiting a porosity gradient showed a promising behaviour after implantation in rabbits' femur: newly formed bone grew in tight contact with the ceramic in a very short time, no modified cells are induced and bone tissue fills even the inner pores.

Tibial plateau fracture after arthroscopic anterior cruciate ligament reconstruction.

Complications have been described with each technique for reconstruction of the anterior cruciate ligament (ACL) in the knee, both open and arthroscopically assisted. The authors describe a case of tibial plateau fracture occurring 7 months after an ACL reconstruction using the half tunnel technique. The fracture occurred at the tibial fixation site and required open reduction with internal fixation. To our knowledge, only 2 cases of proximal tibial fracture after patellar tendon autograft ACL reconstruction have been previously reported. The authors hypothesize that patellar tendon harvesting with bone blocks and transosseous tibial tunnel can produce a "stress riser" effect and somehow act synergistically to create decreased strength at the level of proximal tibial metaphysis.

Localized pigmented villonodular synovitis of the knee: report of two cases of fat pad involvement.

The localized form of pigmented villonodular synovitis (PVNS) is a rare pathological entity characterized by a limited involvement of the synovium. The knee is most commonly affected. In the knee joint, the disorder generally presents as a nodular, pedunculated lesion protruding into the articular cavity. The lesion is usually revealed by mechanical symptoms such as locking. We report on two cases of localized PVNS that involved the patellar fat pad, an extremely rare area of involvement. Mechanical symptoms were not present. In one case, the lesion reached considerable dimensions without interfering with joint function. Arthroscopic treatment was easily performed. No recurrence was observed at 1-year follow up.

Light and scan electron microscopic analysis of cyclops syndrome: etiopathogenic hypothesis and technical solutions.

The loss of range of motion after anterior cruciate ligament (ACL) reconstruction is one of the most common and most challenging complications of this kind of surgery. Recently, an intercondylar notch fibrous proliferation, called cyclops syndrome because of its arthroscopic appearance, has been identified as one of the specific causes of loss of extension. The incidence of cyclops syndrome is 2%-4% [17, 18], but there is still no understanding of its etiology. We speculate on the etiology and suggest some technical solutions to reduce this complication. In 180 patients submitted to arthroscopic ACL reconstruction with patellar tendon, we observed in 4 cases a fibrous nodule adherent to the neoligament that caused a loss of extension between 12 degrees and 17 degrees. In all cases, arthroscopic removal of this nodule solved completely the loss of articular motion. The nodules were subjected to light and scanning electron microscope evaluation. We observed numerous, newly formed vessels in all 4 nodules. These vessels were made up of hyperplastic and hypertrophic cells and were surrounded by bundles of disorganized fibrous tissue. No inflammatory cells or bone or cartilaginous tissue was observed. We hypothesize a microtraumatic genesis for cyclops syndrome. Repeated microtraumas expose the graft collagen fibers, which can lead to productive inflammatory process and thence to the formation of the cyclops nodule. We suggest some technical solutions to avoid graft impingement with the notch and with the tibial bone tunnel.

Bone-ligament interaction in patellar tendon reconstruction of the ACL.

The bone-ligament junction is one of the most complex biological tissues. Its key function is distribution of mechanical loads applied to the ligament in such a way as to diminish the concentration of stresses or shearing at the interface. This paper reports an experimental assessment of the extent to which a nearly normal junction is formed following reconstruction of the anterior cruciate ligament (ACL) with patellar tendon in 20 New Zealand white rabbits sacrificed after 2-38 weeks. A histological comparison was also made with cadaver ACLs. After 5 weeks the new ligament was still separate from the tunnel wall, inflammation was no longer present, and there was no junction tissue. A thin fibrocartilage layer was observed between the bone and the ligament after 12 weeks and was thicker 6 weeks later. After 28 weeks, there was a substantial layer of fibrocartilage. The new junction was virtually "physiological" by the 38th week, with all four layers present. Many fibrocartilaginous cells were also visible between the collagen fibres. The bone-ligament insertion was almost normal. These findings indicate that tendon reconstruction results in the formation of a structure very similar to a physiological junction, and thus ensures better load distribution over a greater ligament insertion area.

Role of arthroscopic lateral release in the treatment of patellofemoral disorders.

The results of 50 arthroscopic lateral releases are reported. The average follow-up period was 36 months with a range of 18-52 months. Satisfactory results were achieved in 71% of 21 patients with patellar pain alone and in 76% of those (Betz RR, Lonergan R, Patterson R. The percutaneous lateral retinacular release Orthopaedics 1982;5:57-62) with instability. Patients with patellofemoral osteoarthritis or patellar dislocation were excluded from the series. Postoperative hemarthrosis occurred in 10%. Unsatisfactory results could be related to incomplete release, severe chondromalacia, or insufficient rehabilitation. Lateral release is capable of producing high rates of success with a low incidence of complication when used to treat patellar pain with tight retinaculum, patellar instability, and subluxation.

[Antero-lateral laxity or a combination of anterior and postero-lateral laxity? Therapeutic considerations]. / Lassità antero-laterale o combinata anteriore e postero-laterale? Considerazioni terapeutiche.

The study involves a group of patients affected with inveterate lesion of the A.C.L. for at least 18 months. Homogeneous two-staged surgical treatment was carried out: 1) reconstruction of the A.C.L. according to Kenneth-Jones; 2) retention of the popliteus according to Bousquet. Results were: excellent: 18; good: 10; fair: 2. Follow-up was obtained after an average of 18 months.