The fate of meniscal tears after anterior cruciate ligament reconstruction.

OBJECTIVE: To investigate the incidence of meniscal pathology and subsequent treatment at an index arthroscopically assisted reconstruction of acute ACL tears (<3 weeks after injury) and to determine the outcome of meniscal pathology. DESIGN: Cohort study with average postoperative follow-up of 40 months (range, 24-76 months). SETTING: University-based sports medicine center. PATIENTS: Series of 162 patients admitted between January 1989 and July 1993. Follow-up was obtained for 105 patients. MAIN OUTCOME MEASURES: Initial presence, location, and treatment of meniscal tears. Subsequent surgery performed and further investigation or surgery being planned. RESULTS: Approximately 40% of patients had meniscal pathology at the index procedure. Most tears were in the lateral meniscus (34 of 45). All posterolateral tears and most other small tears were left untreated (25 of 45). Partial meniscectomies were performed on 17 large, complex, or radial tears that were not amenable to meniscal resuturing. Three meniscal repairs were performed on large, unstable tears. Most patients achieved good functional results. Of the five patients who required late meniscal surgery, three had normal menisci at the index procedure. The other two were asymptomatic until experiencing a reinjury. Despite ACL reconstruction in the acute phase, only two patients required treatment for postoperative arthrofibrosis. Three patients required revision ACL reconstruction after return to full activities and experiencing reinjuries. CONCLUSIONS: Stable tears of both lateral and medial menisci remain asymptomatic at 2 to 6 years' follow-up if treated conservatively. Those requiring further surgery had de novo tears or tears that were asymptomatic before reinjury. Although repair may be of benefit for large flap or bucket-handle tears, it does not appear necessary for most tears and may increase the incidence of postoperative stiffness.

Knee pain after tibial nailing.

OBJECTIVE: To determine the incidence and natural history of knee pain following tibial nailing. DESIGN: A retrospective analysis of patients treated by tibial nailing evaluating a consecutive series of patients with isolated tibial shaft fractures. SETTING: A level one trauma center in Vancouver, British Columbia. PATIENTS: A group of 107 consecutive patients with 110 tibial fractures treated by interlocking tibial nailing. INTERVENTION: Patients were contacted and interviewed by the authors. Clinical records and radiographs were analysed. MAIN OUTCOME MEASUREMENTS: Incidence of knee pain; time of onset; relationship of nail position on radiographs to knee pain; relationship to knee pain to site of nail insertion; response to nail removal. RESULTS: At a mean follow-up period of thirty-two months (12-58 months), sixty-one (57%) patients (63 of 110 knees) had developed anterior knee pain. There was no correlation between nail protrusion and knee pain. Insertion of the nail through the patella tendon was associated with a higher incidence of knee pain compared to the paratendon site of nail insertion (77% and 50% respectively). Of patients with knee pain, 80% (49/61) required nail removal. At a mean duration of 16 months following nail removal, pain was completely relieved in 22 patients and partially relieved in 17. In the remaining 10 patients, there was no improvement. CONCLUSIONS: Based on this data, we would recommend a parapatellar tendon incision for nail insertion, and nail removal for those patients with a painful knee. The causes of knee pain after tibial nailing are multi-factorial and require further study.