Different regional healing rates with the outside-in technique for meniscal repair.

Fifty-one patients with meniscal repair using the outside-in technique were reassessed with second-look arthroscopic procedures (N = 15), arthrographic examination (N = 41), magnetic resonance imaging (N = 36), or a combination of these techniques. Forty-one medial and 10 lateral menisci were repaired. The average clinical follow-up was 15 months (range, 3 to 80). Forty-five of 51 patients had tears that were located in or extended into the posterior horn of the medial or lateral meniscus. Complete healing occurred in 23 menisci (45%), partial healing was observed in 16 (15 medial, 1 lateral) (32%), and no healing occurred in 12 (24%). Remarkably, in all 15 patients who had tears extending from the posterior to the middle third of the medial meniscus that were partially healed, it was always the posterior third that had not fully healed. This finding is statistically significant. In addition, the middle third of these menisci had not fully healed in five patients. No healing occurred in the two patients with tears in the posterior third of the medial meniscus. Poor healing with the outside-in technique was observed in patients with tears into the posterior horn of the medial meniscus. For tears in the middle and anterior portion of the medial meniscus, as well as all lateral meniscus tears, the outside-in technique is our current method of choice.

Arthroscopic meniscal repair with fibrin clot of complete radial tears of the lateral meniscus in the avascular zone.

Peripheral lateral meniscal tears are amenable to arthroscopic meniscal repair. However, the posterolateral aspect of the lateral meniscus adjacent to the popliteus tendon is devoid of penetrating peripheral vessels and therefore difficult to heal. A complete radial split at this site is usually treated with total meniscectomy. We report five cases of a tear of the posterolateral aspect of the lateral meniscus anterior to the popliteus fossa. All patients had a radial split that extended to the popliteus tendon. In all cases, the repair was enhanced with a fibrin clot. Second-look arthroscopy showed that healing of the periphery occurred in all of the cases. All patients returned to their initial level of sports activity. Three of five patients were available for follow-up at an average of 71 months, and magnetic resonance imaging was performed at that time to assess the previously repaired meniscus. All menisci were fully healed and showed no further signs of degeneration. The ability of an exogenous fibrin clot to stimulate and support a reparative response in the avascular portion of the meniscus may represent a potential method of repair. Awareness of the relatively low healing potential of this zone and enhancement of healing opportunities should improve outcome.

The use of noncontrast magnetic resonance imaging in evaluating meniscal repair: comparison with conventional arthrography.

The objective of this study was to investigate whether new and different specialized fast spin-echo techniques could be used to accentuate signal within the site of meniscal repair, obviating the need for intra-articular contrast. With the use of the frequency-selective fat suppression technique, we were able to accentuate fluid in the repair site because of the inherent extended dynamic contrast range of the technique. We performed a blinded study to correlate specialized magnetic resonance imaging (MRI) sequences with standard contrast arthrography, which was used as a standard of reference. Thirty-six patients (36 meniscal repairs) agreed to have MRI followed by contrast arthrography of the affected knee, irrespective of their clinical symptoms. We found that MRI had a very high correlation with arthrography in assessing meniscal repair, with statistical significance. In eight cases that had a second-look arthroscopy, we were able to see that MRI proved to be more accurate than arthrography in discriminating partial or complete healing. This is the first report to show that specialized noncontrast MRI sequences are more effective in evaluating the physiological state of the repaired meniscus, without artifactual distention of the joint recesses by contrast and air. Noncontrast MRI can obviate the need for arthrography in assessment of meniscal repair.

Popliteomeniscal fasciculi and lateral meniscal stability.

In an attempt to understand better the contribution of the anteroinferior and posterosuperior popliteomeniscal fasciculi to lateral meniscus stability, we objectively evaluated the stability of the lateral meniscus before and after sequentially sectioning these fasciculi. In the biomechanical model, we attempted to account for the inherent limitations of arthroscopic evaluation of lateral meniscal stability. When the fasciculi were intact, the average lateral meniscal motion with a 10-N load was 3.6 mm. When the anteroinferior fascicle was disrupted, the average lateral meniscal motion with a 10-N load was 5.4 mm. The mean increase in motion from the intact state was 1.8 mm or 50%, which was significant. When both fasciculi were disrupted, the average lateral meniscal motion with 10-N load was 6.4 mm. The mean increase in motion from the intact state was 2.8 mm or 78% and from the single fascicle disruption state was 1.0 mm or 18%, both differences were significant. The meniscus did not become locked with any of these loading trials, and it spontaneously reduced to the original position when unloaded. Both fasciculi make significant contributions to meniscal stability. Even though the meniscus never became locked in the joint when loaded during this study, with the variable loads seen with normal activities mechanical symptoms might be expected when meniscal motion is almost double. An increase in lateral meniscal motion at the time of surgery may aid in the diagnosis of fasciculi disruption, despite normal meniscal structure on magnetic resonance images and at arthroscopic visualization.

Popliteomeniscal fasciculi and the unstable lateral meniscus: clinical correlation and magnetic resonance diagnosis.

We hypothesize that disruption of the fascicular attachments between the popliteus and lateral meniscus can result in gross instability of the meniscus producing locking of the knee. This study brings attention to the importance of the clinical examination, and the need for clinical correlation to magnetic resonance (MR) studies. We report on three patients referred with the history of mechanical locking episodes of their knee. Initial MR examinations were all read as normal before referral to our institution. On close review of these MR examinations, popliteomeniscal fascicular disruption could be seen in each case. Each of these patients had arthroscopic-repair of these meniscal detachments. At 1-year follow-up, all patients had resolution of mechanical symptoms. Each patient had confirmation of their repair with repeat arthroscopy or MR and arthrographic examinations. An anatomic specimen was used to identify the popliteus muscle and tendon, the lateral meniscus, the antero-inferior popliteomeniscal fascicle, and the postero-superior popliteomeniscal fascicle attachments. MR images of the same anatomic specimen show both superior and inferior fasciculus attachments to the capsule. MR examples of the intact and disrupted antero-inferior and postero-superior popliteomeniscal fasciculi have been correlated to anatomic specimens to help familiarize the orthopaedic surgeon with these important stabilizing structures.

MR imaging based strategies in limb salvage surgery for osteosarcoma of the distal femur.

OBJECTIVE: To analyse to what extent MR imaging based decisions were correct in determining the surgical procedure in patients with osteosarcoma of the distal femur. DESIGN: We compared the findings on MR imaging that determined the surgical strategy with the actual surgical findings or histopathological specimen. We assessed to what extent MR images could be used to determine the surgical procedure in patients with osteosarcoma. PATIENTS: Between 1985 and 1992, 34 patients with an osteosarcoma were treated. Two patients had a low-grade osteosarcoma. Thirty-two patients with a high-grade osteosarcoma of the distal femur (17 stage IIB, 15 stage III) were included in this study. Surgical options consisted of either limb salvage surgery or ablative surgery, which included the Van Nes-Borggreve rotationplasty. Limb salvage surgery consisted of extra-articular or transarticular resection, followed by reconstruction. Surgery was planned depending on the local extent of the tumour as depicted on the MR studies, coupled with data from the biopsy, age, patient compliance and histological grade. Follow-up was available in all patients. Nine of 17 patients graded as IIB were alive with an average follow-up of 68 months (range 46-109 months), of whom one has metastases. No local recurrence was encountered. RESULTS: If no tumour involvement on MR imaging was found and this was used as a determining factor, this proved to be correct at subsequent analysis. We found that in eight of 11 cases, when MR images suggested a close relationship between tumour and nerve, an oncologically safe plane could be achieved during surgery. In three, a free plane could not be accomplished, as confirmed at histopathological examination. Hence, when nerve involvement was equivocal on MR imaging we found it valuable to reassess nerve involvement during surgery and reconsider limb salvage surgery. When the decisive factor was the vascular involvement and tumour extension was read as equivocal, it was possible to obtain a oncologically safe plane in six of 13 cases. When comprehensive tumour involvement of any structure was noted pre-operatively, it proved to be correct at histopathological examination, except for one case of assumed vascular involvement that proved to be free. CONCLUSIONS: If no tumour involvement of a structure was found on MR imaging and this was used as a determining factor, this proved to be correct. When nerve involvement was equivocal on MR imaging we found it valuable to reassess nerve involvement during surgery and reconsider limb salvage surgery. Extensive tumour involvement of any structure, as shown by MR imaging, could be used correctly as a decisive argument in planning a surgical procedure.

[Soft-tissue swelling of the foot not always benign]. / Weke-delenzwelling van de voet niet altijd benigne.

Two men aged 17 and 23 years had a swelling on the foot which was neither an abscess nor a ganglion. Histological study revealed Ewing's sarcoma and synoviosarcoma, respectively. In both patients amputation under the knee was performed; nevertheless both developed metastases. In case of a swelling of the foot the possibility of malignancy has to be considered in order to shorten the diagnostic period. Consultation of the 'Commissie voor Beentumoren' may be desirable because of the low incidence and often difficult diagnostic process.

A consultation method addressing the therapist-family system.

This article discusses a method of unlocking a therapeutic system from recursive, cyclical, "more of the same" struggles. Special attention is paid to the therapist-client system relationship as the unit of observation.