Biomedical subjects
Publications and source records attributed to D J Dandy.
We present a case of chondroblastoma of the upper tibia treated by complete arthroscopic excision. The diagnostic difficulties raised by the case are discussed. This method of treatment has not, to our knowledge, been reported in the literature.
Arteriovenous fistula is a rare complication of arthroscopy. We report a human immunodeficiency virus-positive person with haemophilia who 19 months after an arthroscopic synovectomy of the knee presented with increasingly frequent haemarthroses and a palpable thrill over the knee. Angiography confirmed an arteriovenous fistula. The patient was successfully treated by surgical ligation of the communicating vessels. The literature regarding vascular injuries after arthroscopy of the knee is reviewed.
We describe 74 patients with disabling instability of the knee due to isolated anterior cruciate deficiency. None responded to conservative measures or correction of internal derangements. All patients were treated by replacement of the anterior cruciate ligament with the medial third of the patellar tendon as a free graft, supplemented by an extra-articular MacIntosh lateral reconstruction. A satisfactory outcome was found in 93% of knees after an average of 70 months follow-up. Cast immobilisation after operation, the interval between injury and reconstruction, the age of the patient and the severity of symptoms before reconstruction had no significant effect on the final outcome.
Thirty patients underwent partial meniscectomy through two puncture incisions by a closed technique under arthroscopic control. "Bucket-handle" fragments were removed from 17 knees, and flaps or tags from the remainder. The mean stay in hospital after operation was 1.3 days and the mean time for return to working fitness was 10.5 days. There were no serious complications. Further study of the long-term results of this technique is needed.
Twenty patients with an average age of eighteen and a half years sustained osteochondral fractures of the lateral femoral condyle as the result of a sudden twist and valgus strain to the straight or almost straight knee. All the patients felt sudden pain at the moment of injury, all had a haemarthrosis, and yet the fracture escaped early diagnosis in one-third of the cases. Internal fixation of the fragment with early mobilisation is recommended if the diagnosis is made within two weeks of injury, and excision of the fragment if it is only later identified.
Fifty-eight realignment operations for dislocation or subluxation of the extensor mechanism are described. Patellectomy was combined with realignment in 14. Thirty-five of the 44 patients (80 per cent) in whom the patella was retained also had chondromalacia patellae, which improved after realignment in 26 (74 per cent) without shaving or drilling of the articular surface. The symptoms of chondromalacia were more likely to regress if stability of the extensor mechanism was achieved.
One thousand and forty-two McKee-Farrar prostheses of the present design inserted in Norwich from January 1965 to December 1972 have been reviewed retrospectively to determine the incidence of complications needing revision. Of prostheses implanted for more than two years, 6-6 per cent needed revision for loosening (cup 3-5 per cent; stem 2-2 per cent; both components 0-9 per cent). Of the total number, 2-3 per cent became infected and 1-9 per cent dislocated. Most dislocations needed only a single closed reduction but 0-8 per cent were revised. The outcome of revision operations was also assessed. Of revisions for loosening, 40 per cent needed no further operation but 23 per cent required excision; pelvic fracture or bone destruction around the components made success unlikely. Revisions for dislocation were disappointing. Of all revisions 17 per cent became infected. Excision arthroplasty is better than a series of failed revisions in an elderly patient.
A study has been made of 800 consecutive arthroscopic examinations of the knee with special emphasis on the changes in management that resulted. Of 614 knees that would have been operated upon if arthroscopy had not been available, open operation was avoided in 32 per cent, a defferent operation was done or planned in 27 per cent, and there was no important change in the remaining 41 per cent. Of 186 knees that would have been treated conservatively if arthroscopy had not been available, the examination resulted in some immediate benefit to 30 per cent of the patients. There were no wound infections after arthroscopy alone, and the known incidence of incorrect interpretation was 1.4 percent.
The causes of persistent symptoms after meniscectomy have been assessed clinically, radiologically and arthroscopically in 174 knees. The commonest finding was early degenerative arthritis (chondromalacia) of the femoral condyle (40 per cent). Retained fragments of meniscus were less common than expected (13 per cent), and lesions of the other meniscus were rare (5 per cent). The clinical diagnosis was altered in 42 percent by arthroscopic examination. Arthroscopy was found to be a valuable technique in this group of patients with problems of diagnosis.
One hundred and fifty-four knees with 161 torn menisci were examined with the arthroscope immediately before meniscectomy. The incidence of early degenerative arthritis (chondromalacia) of the femoral condyle was correlated with the age of the patient, the interval between injury and surgery, and the type of meniscal lesion. The incidence of condylar chondromalacia was significantly higher in patients over the age of thirty (p less than 0.01) and in those with a history longer than three months (p less than 0.05). Posterior horn tears were associated with the highest incidence of degenerative changes, but were also associated with a longer history and with older patients. Attention is drawn to the adverse effect of damaged menisci on condylar articular cartilage, and a plea is made for early diagnosis and removal of damaged menisci.