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The purpose of this pilot study was to explore the potential of an autogenous tendon graft to substitute for an absent human knee joint meniscus. Based on the results of animal studies and human reports, it was hypothesized that autogenous tendon tissue would substitute for human knee joint meniscus: maintain mechanical integrity, convert to fibrocartilage, preserve the joint compartment, and provide symptomatic relief for the patient. Five patients, 2 men and 3 women, average age 41 years, had surgical absence of the lateral meniscus, genu valgum, and severe degenerative arthritis of the lateral compartment, but a stable knee. All patients were offered alternative treatments: do nothing, medication, arthroscopic debridement, osteotomy, and knee replacement. The operations were performed by arthroscopy. An accompanying arthroscopic debridement procedure was performed in the same compartment. In 4 cases, the donor graft was the semitendinosus tendon. In 1, the patellar tendon was used because the semitendinosus had been previously used in an anterior cruciate ligament reconstruction. Four of the 5 patients had a second-look arthroscopy and biopsy between 9 and 24 months. There was partial physical integrity to the tendon graft. The tendon graft did not completely convert to fibrocartilage. The joint surface was not preserved. Only 1 patient had minimal clinical improvement; the others were not improved. No patient was made worse. One patient had a total knee replacement 1 year later. Another had a knee fusion after 4 years. All other patients are considering future reconstructive surgery. The autogenous tendon graft as used in this pilot study was not successful as a substitute for an absent meniscus. The hypothesis was not realized. The observations from this pilot study should be helpful in future study protocol design.

A novel bioabsorbable suture anchor has been introduced for shoulder rotator cuff surgical repair made of the co-polymer 85/15 D,L lactide/glycolide. Previous clinical reports on the use of this material in anterior cruciate ligament reconstruction have described intraosseous edema at various time intervals following implantation. The purpose of this study was to analyze the implant's loss of physical properties and to correlate magnetic resonance imaging (MRI) finding with gross and histological observations at various time intervals after intraosseous implantation in the experimental animal. Six drill holes were made in the tibias of 11 dogs. The spherical implant was placed in 5 of the drill holes and the sixth was preserved as a sham control. The dogs were killed at 3, 4, 6, 9, 12, and 26 weeks for gross and microscopic inspection. Correlative MRIs were taken from the 4-, 12-, and 26-week specimens. Gross inspection showed that the overlying soft tissue healed to bone in 3 weeks. The implants were surrounded by new bone by 6 weeks. The implants maintained gross physical integrity for 6 to 12 weeks. Histologically, there was minimal inflammatory response to the degrading implant. The implant site had been completely replaced by bone at 12 weeks. Correlative MRI showed edema adjacent to the implant sites, but there was no correlative inflammation or cyst formation through the time necessary for complete absorption of the implant. Correlative MRI identified and differentiated the image of the intact and degrading implant.

The purpose of this study was to establish the incidence of the anatomic structure, the popliteal bursa, in patients undergoing arthroscopy and to determine the relationship to associated clinical and pathological factors. Diagnostic arthroscopy was used to identify the presence of the popliteal bursa in 187 consecutive patients (195 knees). Thirty-seven percent of knees had a popliteal bursa identified by the communication with the posterior medial compartment. The cause of the popliteal bursa was not established by this study. This study refuted the causes proposed by others. The existing erroneous conclusions concerning the cause of the popliteal bursa were probably attributable to the failure to recognize the common continuity of the bursa and the knee joint. When the popliteal bursa is present (37%), it becomes symptomatic by responding to the intraarticular disease because of its continuity with the knee joint.

The purpose of this pilot study was to determine if an accurate diagnosis could be made concerning the knee joint using only the patients' medical history information. Only women were chosen for this study because of existing unpublished data on a cohort of 100 women with normal knees to act as a control (group I). From the 2,266 knee surgical procedures in the database of one surgeon, two other groups were selected. Group II was those women with only a torn medial meniscus. Group III were those women with only a torn anterior cruciate ligament (ACL). The medical history data of one half of the database were statistically analyzed to determine the questions that were the best predictors of each group. The medical history questions discovered to be best predictors were different from what might be expected from an individual surgeon's experience, expert opinion, or a medical consensus opinion panel, but the predictors did have a foundation in fact and are substantiated by statistical analyses. Using these predictors, a validation was performed on the other half of the database. When the top 142 predicting questions were used, the diagnostic accuracy was 98%; 98 of 100 of the "normal" group, 57 of 59 cases classified as having a torn meniscus, whereas 128 of 129 cases classified as having a torn ACL were correctly identified. When the only the 30 strongest predictors were used, the diagnostic accuracy was 85%: 100 of 100 cases were correctly classified as normal, 45 of 59 cases were correctly classified as having a torn meniscus, and 101 of 129 cases were correctly classified as having a torn ACL. This study demonstrated that statistical methods applied to medical historical data can make a differential clinical diagnosis of an unknown knee joint problem with high degree of accuracy and with statistical significance. In the future, computerized medical diagnostic instruments can be constructed using these statistical methods.

The purpose of this laboratory investigation was to determine if there was any difference in the force required to pull out a patellar bone-tendon-bone graft from a femoral bone tunnel when secured by an interference screw of different materials, metal or biodegradable. The tibial end of the bone-tendon-bone graft was placed in the femoral tunnel. A 9-mm metal interference screw was used on the left side, and a 9-mm biodegradable screw was used on the right to secure the graft. Ultimate load to failure was determined by Instron testing. The average load before failure for the graft secured by the metal screw was 436 Newtons and for the biodegradable screw was 565 Newtons. A statistical significance was not demonstrated because there was wide range of loads between donor specimens, probably because of variations in bone density.

Summary The results of a 2-year pilot study on an alternative health-care reimbursement system are presented. This innovative system includes a 2-year warranty by the providers to protect the insured and insurer from additional expenses. It is based on the advantages of arthroscopy. This system provided access, choice, and affordability for 111 patients from a managed care environment who were predetermined to be orthopedic surgical candidates. The unique features included unlimited free consultations and office radiographs. Payment was made only if a patient had surgery. This single fee included all related physician and hospital charges for surgery and any subsequent service for the next 2 years under the warranty. The profit margin for the providers was based on the application of arthroscopy, which anticipated reduction in the customary hospitalization. Accountability was provided by reporting of surgical indications and incidence. The surgical incidence of 42% was less than what was projected. The health maintenance organization insurer saved in excess of $125,000.00. Both the hospital and the surgeon earned more than under existing reimbursement systems.

This report illustrates the outcome of a free human autogenous semitendinosus tendon graft placed in the knee under arthroscopic control for anterior cruciate ligament reconstruction. The tendon graft showed signs of injury by localized loss of normal histochemical staining properties. The cellularity was not diminished in an early (3-week) specimen. The resultant composite anterior cruciate ligament consisted of two distinct areas: tendon graft and surrounding fibrous tissue. The tendon maintained gross and microscopic characteristics of the original tendon. The tissue surrounding the tendon graft had a disorganized cellular pattern and hypervascularity. The tendon graft in this study did not show gross or microscopic evidence of death and reorganization. Previous reports have led to erroneous conclusions concerning the outcome of a free tendon graft due to inaccurate biopsy site of the reorganizing fibrous tissue surrounding the tendon graft.

Summary The purpose of this article is to report the arthroscopic findings before and immediately after manipulation for frozen shoulder. Twenty patients were selected for manipulation under general anesthesia after failing to improve with conservative measures in 6 months. The findings showed the joint capsule was difficult to penetrate with the arthroscope cannula and obturator because of the thickness of the capsular tissue. The glenohumeral joint accepted less than the normal amount of fluid. The humeral head was tight against the glenoid even in the suspended position. The main intraarticular finding was vascular synovitis. There were no intraarticular adhesions or degenerative changes. An immediate postmanipulation second-look arthroscopy showed there was synovial and capsular hemorrhage indicative of tearing from the manipulation. After glenohumeral manipulation, the joint accepted more fluid, and the humerus was easily distracted away from the glenoid with intraarticular distention.

The immediate postoperative bleeding and blood clot formation was observed in 26 human knee joints following a variety of arthroscopic surgical procedures. Observations were made following lavage with lactated Ringer's and normal saline solutions. Bleeding occurred from all incised vascular tissue. Blood clot accumulated after each solution within 5 min following tourniquet release and decompression of the joint. Most of the blood clot remained unattached within the joint cavity. Blood clot did attach to all surgically incised or excised surfaces. The clinical relevance of these observations is related to the potential role of the blood clot in intraarticular tissue repair following arthroscopic surgery.

This article describes repair of osteochondritis dissecans of the knee by arthroscopic compression screw fixation and reports the healing response and clinical result. Diagnostic and operative arthroscopy was performed. Compression screw fixation was used. The exact operative technique varied depending on the status of the lesion. The patients were non-weight bearing for 2 months, after which a second surgery was necessary for removal of the metallic screw(s). The initial healing response was assessed by the firmness of the lesion to palpation at the second look. Subsequent x-ray evidence of healing was correlated with the clinical outcome. Ninety-four percent of the knees were determined to be initially healed at the time of the second look. Four of these apparently solid repairs subsequently loosened and required repeat surgery. Eighty-eight percent of the patients assessed their results as excellent or good after 2 years minimum follow-up. Arthroscopic compression screw fixation is an effective method of repair for mild to moderately severe cases of osteochondritis dissecans.

Arthroscopic abrasion arthroplasty is a modification of open Magnusson "housecleaning" arthroplasty. The arthroscopic approach decreases incision size enhancing postoperative rehabilitation. Arthroscopic techniques enhance the accuracy of diagnosis and provide accuracy of limiting debridement only to diseased tissue in various other dimensions of arthroplasty. The abrasion of a sclerotic lesion superficially removes dead bone, exposes vascularity providing a tissue bed for blood clot attachment. Postoperative joint protection provides an environment for clot organization and fibrous tissue formation. Subsequent fibrocartilage formation has maintained integrity for up to 6 years, the extent of experience. The clinical indication is pain. The patient benefit, therefore, is also subjective. Objective evidence of healing response is demonstrated by second-look arthroscopy, biopsy, and comparison x-ray films. If nothing else, these clinical and pathological observations have challenged "established concepts" and opened new vistas for investigation.