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Objective: This report focuses on the biological events occurring at various intervals following autogenous bone grafting of large-volume defects of the knee joint’s femoral condyle secondary to osteochondritis dissecans (OCD) or osteonecrosis (ON). It was hypothesized that the autogenous bone graft would integrate and the portion exposed to the articular surface would form fibrocartilage, which would endure for years. Methods: Between September 29, 1987 and August 8, 1994, there were 51 patients treated with autogenous bone grafting for large-volume osteochondral defects. Twenty-five of the 51 patients were available for long-term follow-up up to 21 years. Patient follow-up was accomplished by clinical opportunity and intentional research. Videotapes were available on all index surgeries for review and comparison. All had preoperative and postoperative plain film radiographs. Long-term follow-up included MRI up to 21 years. Second-look arthroscopy and biopsy were obtained on 14 patients between 8 weeks and 20 years. Results: Radiological assessment showed the autogenous bone grafts integrated with the host bone. The grafts retained the physical geometry of the original placement. MRI showed soft tissue covering the grafts in all cases at long-term follow-up. Interval biopsy showed the surface covered with fibrous tissue at 8 weeks and subsequently converted to fibrocartilage with hyaline cartilage at 20 years. Conclusion: Autogenous bone grafting provides a matrix for large osteochondral defects that integrates with the host bone and results in a surface repair of fibrocartilage and hyaline cartilage that can endure for up to 20 years.

Background Dextrose injection is reported to improve knee osteoarthritis (KOA)−related clinical outcomes, but its effect on articular cartilage is unknown. A chondrogenic effect of dextrose injection has been proposed. Objective To assess biological and clinical effects of intra-articular hypertonic dextrose injections (prolotherapy) in painful KOA. Design Case series with blinded arthroscopic evaluation before and after treatment. Setting Physical medicine and day surgery practice. Participants Symptomatic KOA for at least 6 months, arthroscopy-confirmed medial compartment exposed subchondral bone, and temporary pain relief with intra-articular lidocaine injection. Intervention Four to 6 monthly 10-mL intra-articular injections with 12.5% dextrose. Main Outcome Measures Visual cartilage growth assessment of 9 standardized medial condyle zones in each of 6 participants by 3 arthroscopy readers masked to pre-/postinjection status (total 54 zones evaluated per reader); biopsy of a cartilage growth area posttreatment, evaluated using hematoxylin and eosin and Safranin-O stains, quantitative polarized light microscopy, and immunohistologic cartilage typing; self-reported knee specific quality of life using the Western Ontario McMaster University Osteoarthritis Index (WOMAC, 0-100 points). Results Six participants (1 female and 5 male) with median age of 71 years, WOMAC composite score of 57.5 points, and a 9-year pain duration received a median of 6 dextrose injections and follow-up arthroscopy at 7.75 months (range 4.5-9.5 months). In 19 of 54 zone comparisons, all 3 readers agreed that the posttreatment zone showed cartilage growth compared with the pretreatment zone. Biopsy specimens showed metabolically active cartilage with variable cellular organization, fiber parallelism, and cartilage typing patterns consistent with fibro- and hyaline-like cartilage. Compared with baseline status, the median WOMAC score improved 13 points ( P = .013). Self-limited soreness after methylene blue instillation was noted. Conclusions Positive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA, suggesting disease-modifying effects and the need for confirmation in controlled studies. Minimally invasive arthroscopy (single-compartment, single-portal) enabled collection of robust intra-articular data. Level of Evidence IV

Background: Traditional pain assessment instruments are subjective in nature. They are limited to subjective reporting of the presence and magnitude of pain. There is no means of validating their response or assessing their pain tolerance. The objective of this study was to determine the potential value of a novel addition to the traditional physical examination concerning a patient’s pain and more importantly their pain tolerance. Methods: Extensive preliminary data were collected on 359 consecutive private practice knee patients referable the subject’s pain, including the magnitude, the most pain ever experienced, and their opinion of personal pain tolerance. The novel evaluation included physical testing of a series of small ball drops through a vertical tube from various fixed levels on the index finger and patella. The patient’s response to this impact testing provided quantitative information, from which a comparison was made to their pain opinion and also to that of other patients with similar demographics. Results: Nine percent of the patients rated their pain tolerance below the midpoint on the visual analog scale. Seventy-one percent thought they were above the midpoint on the scale in regards to pain tolerance. There were discrepancies in both directions between the subject’s opinion on pain tolerance and their rating of their pain experience to the ball drop testing. Twenty-eight percent of the entire patient group rated themselves above 5 on tolerance, but experienced above the average discomfort compared to other subjects reporting on the finger impact testing. Conclusions: This report introduces a novel method for collecting data concerning pain that can be subjected to quantification. The database included quantitative measures providing the opportunity to confirm, validate or refute the patient’s assertions concerning pain magnitude and tolerance. This method is best described as a patient pain profile. It has the potential to give both the patient and the physician quantified objective information rendering insight not otherwise available. J Clin Med Res. 2015;7(10):781-790 doi: http://dx.doi.org/10.14740/jocmr2277e

Objective: We report the long-term clinical outcomes of patients who underwent autogenous bone grafting of large-volume osteochondral defects of the knee due to osteochondritis dessicans (OCD) and osteonecrosis (ON). This is the companion report to one previous published on the biological response. We hypothesized that these grafts would integrate with host bone and the articular surface would form fibrocartilage providing an enduring clinical benefit. Design: Three groups (patients/knees) were studied: OCD without a fragment ( n = 12/13), OCD with a partial fragment ( n = 14/16), and ON ( n = 25/26). Twenty-five of 52 patients were available for clinical follow-up between 12 and 21 years. Electronic medical records provided comparison clinical information. In addition, there were plain film radiographs, MRIs, plus repeat arthroscopy and biopsy on 14 patients. Results: Autogenous bone grafts integrated with the host bone. MRI showed soft tissue covering all the grafts at long-term follow-up. Biopsy showed initial surface fibrocartilage that subsequently converted to fibrocartilage and hyaline cartilage at 20 years. OCD patients had better clinical outcomes than ON patients. No OCD patients were asymptomatic at anytime following surgery. Half of the ON patients came to total knee replacement within 10 years. Conclusions: Autogenous bone grafting provides an alternative biological matrix to fill large-volume defects in the knee as a singular solution integrating with host bone and providing an enduring articular cartilage surface. The procedure is best suited for those with OCD. The treatment for large-volume articular defects by this method remains salvage in nature and palliative in outcome.

The present day practice of medicine is cause of considerable malaise for physicians. This article will invoke the ancient proverb, "Physician Treat Thyself". In other words this article addresses the problems from a diagnostic and therapeutic perspective, working toward a permanent cure. The history of medical practice groups, in-office surgery, and ancillary services is reviewed. The co-morbidity of health maintenance organizations, Evaluation and Management requirements, and cost shifting are mentioned. Finally a list of symptoms and the appropriate therapeutic measures are administered to control costs, increase income, and re-establish some form of authority in the practice of medicine.

Arthroscopic abrasion arthroplasty is an elaborate description for an extensive multiple tissue debridement for patients seeking an alternative to total knee replacement. The operation is palliative, not curative. In patients seeking an alternative to total knee replacement, the definitive operation may be avoided or deferred in a high percentage of patients as many as 5 years. Because the abrasion portion of the operation is accompanied by multiple tissue type debridement, it is not known what clinical benefit the abrasion aspect contributes. Furthermore, no prospective randomized clinical studies have been done and most clinicians reporting on their experience with the procedure have varied the indications, technique, and/or postoperative treatment. Future investigation may answer these clinical questions. It is known that fibrocartilage forms at the abrasion site. The reparative tissue has many of the characteristics of cartilage, but does not have the biomechanical properties of articular cartilage. The fibrocartilage has shown durability for many years confirmed during opportunistic second look arthroscopy. The applications of growth factor science or genetic engineering may provide means of converting the regenerative tissue of abrasion arthroplasty to mature articular cartilage.

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.

An anatomic structure frequently observed during glenohumeral joint arthroscopy is described as the vincula of the long head of the biceps brachia tendon. These vincula were present in 24.3% of 411 shoulders (390 patients) undergoing shoulder arthroscopy. There was single vinculum in 56 shoulders, two vincula in 32, three in 12, and four in one shoulder. Younger age is a significant predictor of the presence of vincula. The presence of vincula was also related to subacromial impingement and glenoid labrum tearing. The absence of vincula was related to the diagnosis of rotator cuff tearing. The gross and microscopic structure is similar to the vincula of the finger flexor tendons.

Summary This study evaluated early changes in full-thickness (FT) and partial-thickness (PT) articular cartilage defects created by arthroscopic surgery. The defects were of various configurations in a model (horse) that was weight-bearing immediately after surgery. The objectives were to evaluate recellularization and to examine the effect defect configuration had on adjacent cartilage cellularity and proteoglycan content. Thirty-six PT lacerations, FT lacerations, PT scrapes, PT craters, and FT craters were created in the antebrachiocarpal and intercarpal joints of eight adult horses. The configurations were lacerations by knife blade, scrapes by a curette, and craters created by motorized burr. Horses were euthanized one, three, and eight weeks after surgery. Histologic examination was performed using hematoxylin and eosin and safranin-O staining. All FT craters showed evidence of early repair. None of the lacerations showed evidence of early repair. One PT scrape and four PT craters bad fibrous tissue within the defect. All defects had degenerative changes in adjacent cartilage. Craters and scrapes had significantly worse degenerative changes than lacerations. Patients undergoing arthroscopic surgery who will be weight-bearing immediately after surgery should have full thickness crateriform debridement if a healing response is desired. Partial thickness debridement does not show evidence of repair. Degenerative changes in adjacent cartilage occurred in all defects and they are directly proportional to the amount of trauma and instrumentation used at surgery. Full thickness (FT) cartilage defects that penetrate the zone of calcified cartilage rely on hemorrhage from subchondral bone and the resultant fibrin clot to initiate repair. The fibrin clot acts as a matrix for cellular repair that results in formation of fibrous tissue. The quality of repair (i.e. fibrous tissue, fibrocartilage, or hyaline cartilage) relies on metaplasia of fibrous tissue. This mechanism of articular cartilage healing, referred to as extrinsic repair 1,2 occurs after subchondral abrasion with motorized instrumentation; 3,4,5 however, the quality and durability of repair tissue has been questioned. 5,6,7 Partial thickness (PT) cartilage defects do not penetrate the zone of calcified cartilage and do not bleed. Healing of PT defects relies on mitotic activity of chondrocytes and increased metabolic activity adjacent to the defect to create intrinsic repair. 2 Many investigators have shown the inability of PT defects to heal. 3,8,9,10,18 It has recently been shown that PT defects may undergo further degeneration. 3 The fibrin clot and other extrinsic factors released during hemorrhage in FT defects are reported to be important in initiating repair of articular cartilage. 5 Mesenchymal cells from the subchondral bone initiate the recellularization process in FT defects. 11,12,13 If PT defects are to heal with any degree of consistency then a “modified” extrinsic repair must occur or blood clot must attach to the defect and recellularization from synovial cells within the joint must take place. Early reparative changes in articular cartilage of other species have been documented. Most studies investigating articular cartilage healing in the horse are long-term studies evaluating the quality and durability of repair tissue. The purpose of this study was to investigate early recellularization of FT and PT defects created by arthroscopic surgery in articular cartilage located within the same joint surface in a model in which the operated horse was weight-bearing immediately after surgery. The objectives were to evaluate early recellularization and to examine the effect various types of defects had on adjacent cartilage cellularity and proteoglycan content at one, three, and eight weeks after surgery.

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 purpose was to explore whether there were any pathological characteristics of the end-stage osteoarthritic sclerotic lesion that have potential to participate in cartilage repair. Specimens harvested following total knee surgery were examined for gross pathology including staining with Safranin O. Multiple small sections of the lesion were placed in tissue culture for 6 weeks. Gross examination and photographic documentation was made at 3 and 6 weeks. At 6 weeks the specimens from culture were subject to histological examination. The pathology of the end-stage osteoarthritic lesion showed sclerotic bone, dead osteons, hypervascularity and scattered cartilaginous aggregates. Additional observations showed multiple pitting on the sclerotic surface, which histologically was related to three events; fragmentation of dead bone, ruptured blood vessels, and eroded aggregates. There were no pathological or biological changes in the specimens following the time in tissue culture. The in-depth pathological evaluation showed the end-stage osteoarthritic lesion to have certain features with potential to facilitate cartilage repair. The cartilaginous aggregates may be a participant in cartilage repair following surgery. The cartilaginous aggregates remained unchanged in the tissue culture absent the normal synovial joint chemical and physical environment and therefore further testing with a different experimental model would be necessary to establish these aggregates as a source of cartilage regeneration. The multiple small depressions in this lesion may have potential to be a “home” for therapeutics.

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.

Objective(s): To assess biological and clinical effects of intra-articular hypertonic dextrose injections in painful severe knee osteoarthritis (KOA). Hypertonic dextrose injection is reported to improve KOA-related pain, stiffness and function, but its effect on articular cartilage is unknown. Design: Open label pilot study. Setting: Outpatient pain medicine and day surgery practice. Participants: Adults with knee pain for at least 6 months, arthroscopyconfirmed medial compartment Outerbridge IV KOA, and temporary pain relief with intra-articular lidocaine injection. Interventions: 6 monthly 10 mL intra-articular injections with 12.5% dextrose. Main Outcome Measure(s): Assessed at baseline and 7.5 2.0 (range 4.59.5) months: Video arthroscopy of 9 standardized medial condyle zones was performed before and after treatment; semi-quantitative visual cartilage growth assessment of each zone (+1.0,-1) was performed by 3 surgeon-reviewers. Biopsies of cartilage growth-area was obtained posttreatment and evaluated using HE Fleiss kappa Z0.901).Biopsy specimens showed metabolically active cartilage with variable cellular organization, fiber parallelism, and cartilage typing patterns consistent with fibroand hyaline-like cartilage. Compared with baseline status, participants reported improved WOMAC scores (17.6 4.7 points; pZ.013). Self-limited soreness after methylene-blue instillation was noted. Conclusions: Positive clinical and chondrogenic effects were seen after hypertonic dextrose injection in symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies.

Various noninvasive or minimally invasive methods have been reported in the treatment of delayed union of long-bone fractures.1–7 Minimal incisions have been used for prophylactic bone grafting for high-energy fractures.8

The purpose of this study was to explore the potential of applying arthroscopic techniques to autogenous bone grafting of long bone fracture delayed union. There were 9 patients in this initial series, including 4 patients (average age, 37 years) with humeral lesions and 5 patients (average age, 25 years) with tibial fractures. There were 6 men and 3 women. Techniques customarily employed in arthroscopy were used to visualize, expose, and deliver the onlay cancellous bone grafts. Bony union occurred in all but 1 patient in an average of 4 months. This patient had a fibrous union and sustained a reinjury that led to successful repeat open bone graft surgery. The arthroscopic approach for bone grafting of certain long bone delayed union appears to be a safe and effective procedure. The procedure is best suited for patients with mechanically stabilized fragments, and it lends itself to those with overlying skin or soft tissue compromise. There are some relative contraindications: grossly unstable fragments, severe malunion, and/or infection.

Two hundred ten adults, 100 women and 110 men, were recruited on the condition of always having asymptomatic knee joints. These recruits were initially solicited by newspaper advertisement. The women were recruited in 3 weeks, but additional efforts and 3 months were necessary to assemble the group of men. The volunteers underwent a uniform comprehensive medical history questionnaire, physical examination, and plain film radiographs. The data collected were subjected to computerization and statistical analysis. Although these subjects were always asymptomatic, only 4.5% of 200 women's knees and 21% of 220 men's knees had no "positive" physical findings. The findings of hypermobile patella, patellar crepitus, and lateral patellar position on Merchant x-ray view were common. Findings not present or infrequent in these asymptomatic subjects and potentially pathological were patellar J-sign, decreased range of motion, asymmetrical ligamentous laxity, McMurray's sign, compartmental crepitus, and severe degenerative arthritis or loose bodies on radiograph. The findings in women were different from those observed in men. This gender-specific information should be helpful in patient management but also useful and timely for establishing practice guidelines, treatment algorithms, and outcome study instruments. Arthroscopy 1998 May-Jun;14(4):347-59

Autogenous cancellous bone was evaluated as a material to repair large osteochondral defects in 20 adult mongrel dogs. In one knee, the bone graft was used to fill an osteochondral cylindrical defect (10 mm diameter × 10 mm deep) created in the femoral trochlea. A similar lesion was created in the contralateral knee but was left untreated for spontaneous healing. Four animals were killed at each of five periods (2, 4, 8, 12, and 24 weeks), and the healing response of the defects was evaluated by gross anatomic inspection, plain film radiography, high-resolution radiography, and histology. The results of this study suggest that the use of a cancellous bone graft accelerates the repair of large osteochondral defects and produces more uniform filling of the defect than the ungrafted control. The reparative surface of the grafted lesions also differed from that of controls, having uniform coverage with histochemical-positive staining fibrocartilage at 8 weeks, a finding not observed in any control defect through the length of this study, 24 weeks. Arthroscopy 1998 Apr;14(3):311-20

The purpose of this study was to determine the initial effects of Holmium:YAG laser energy on the shoulder joint capsule. A new surgical procedure to correct shoulder joint instability uses Holmium:YAG laser energy to cause "shrinkage" of joint capsular tissues. To date there has been no information concerning an intraoperative measurable end point for the application of laser energy at surgery or the resultant depth and degree of tissue alteration. Seven greyhound dogs were used in this study. Preoperative intraarticular pressures (IAP) were measured on entry and after injection of 10 ml of solution. Laser energy was applied to the cranial medial glenohumeral ligament and joint capsule of all right shoulders with arthroscopic visualization. The unoperated left shoulders served as the control group. Six weeks after surgery pressure measurements were performed on both shoulders. A "second look" arthroscopy was performed on the shoulders. After euthanasia was performed, the anterior capsular tissues were harvested from both shoulders for histologic examination. The specimens were inspected by three blinded examiners. After 6 weeks the postoperative laser-treated IAP were higher than the same joint preoperative IAP in four of six dogs for both static nondistension and 10 ml distension measurements. At this same interval the marked tissue damage of the treated capsule was easily discerned by blinded observers. On histologic evaluation the laser-treated capsule showed synovitis and pericapsular tissue reactivity. The depth of the injury was beyond the joint capsule into the pericapsular tissue. It was not possible to determine the end point of the capsular "shrinkage" operation by combined pressure/volume intraoperative measurements. There was no uniform joint capsule compliance at 6 weeks. The histologic changes were extensive in both magnitude and depth. Future studies in this animal should include decreased laser energy plus other means of monitoring the intraoperative effects of laser use. (J Shoulder Elbow Surg 1997;6:272-85.)

Comparison of perilesional cartilage, lesional repair tissue, and subchondral bone activity 6 months after application of holmium-yttrium-aluminum-garnet (Ho:YAG) laser energy to chronic (10 week) induced 10-mm full-thickness (FT) circular articular cartilage craters followed by 6 months' intermittent active motion (IAM) in a free exercise environment was investigated. The 2.1-microns wavelength was delivered in hand-controlled near-contact mode by arthroscopic surgery in a saline medium. Bilateral arthroscopy was performed on normal antebrachiocarpal, intercarpal, and metacarpophalangeal joints of six adult horses. Full-thickness craters were created in nine sites per limb on weight-bearing articular surfaces with a motorized bur. Right limb craters served as sham operated controls. Animals were killed at 10 weeks after FT crater creation (n = 2), and at 24 weeks (6 months) after laser energy application (n = 4). Histological analysis using hematoxylineosin (HE) and Safranin-O staining consisted of a modified Mankin grading of perilesional cartilage and lesional repair tissue scoring. Biochemical analysis was performed for cellularity and glycosaminoglycan (GAG) synthesis. Histological analysis showed clustering of chondrocytes or perilesional zonal cloning (PZC) in 83% of laser-treated lesions and in no control lesions. No differences were observed between treated and control lesional repair activity. Laser-treated perilesional cartilage showed a significant (P.02) decrease in GAG synthesis. No adverse effects to distant cartilage were observed after application of laser energy regarding cell proliferation or GAG synthesis. Significance of decreased GAG synthesis in treated perilesional cartilage and perilesional zonal cloning of chondrocytes in treated cartilage is unknown. Additional study of Ho:YAG laser energy application to cartilage and subchondral bone is needed before its application in the surgical management and repair of cartilage damage.

The effects of Ho:YAG laser energy on articular cartilage and subchondral bone adjacent to traumatically created cartilage lesions in a continuous weight-bearing model were investigated. The 2.1 micrometers wavelength was delivered in hand-controlled contact and near-contact hard tissue arthroscopic surgery in a saline medium. Bilateral arthroscopy was performed on normal antebrachiocarpal and intercarpal joints of four adult horses. One-hundred twenty traumatic lesions were created on three weight-bearing articular surfaces with a knife, curette, or a motorized burr. Depths of the lesions were partial and full thickness. Configurations of the lesions were lacerations, scrapes, and craters. Left limbs were used as controls. Right limb lesions were treated with various intensities of laser energy. Animals were sacrificed at intervals of 1, 3, and 8 weeks. Gross microscopic anatomy was documented, and tissue sections were subjected to blind review by a pathologist. Mankin grading for cellularity and proteoglycan content was used to qualitatively evaluate cartilage response. Cartilage adjacent to all lesions exposed to laser energy had better cellularity and proteoglycan content than corresponding controls by Mankin grading.© (1994) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

This study was performed to investigate the effects of holmium:yttrium-aluminum-garnet (Ho:YAG) laser energy on articular cartilage and subchondral bone adjacent to traumatically created cartilage lesions in a continuous weight-bearing model. The 2.1-microns wavelength was delivered efficiently and precisely in hand-controlled contact and near-contact hard tissue arthroscopic surgery in a saline medium. Bilateral arthroscopy was performed on normal antebrachiocarpal and intercarpal joints of four adult horses. One hundred twenty traumatic lesions were created on three weight-bearing articular surfaces with a knife, curet, or motorized burr. Depths of the lesions were partial and full thickness. Configurations of the lesions were lacerations, scrapes, and craters. Left limbs were used as controls. Right limb lesions were treated with various intensities of laser energy: 0.1. 0.16, and 0.2 J. Animals were killed at intervals of 1, 3, and 8 weeks. Gross microscopic anatomy was documented, and tissue sections were subjected to blind review by a pathologist. Mankin grading for cellularity and proteoglycan content was used to qualitatively evaluate cartilage response. Cartilage adjacent to all lesions exposed to laser energy had better cellularity and proteoglycan content (p0.05) than did corresponding controls by Mankin grading. Mankin grades for levels of 0.16 and 0.2 J were lower (p0.05) than were those of controls or lesions exposed to 0.1 J. There was loss of cellularity and necrosis in subchondral bone at higher energy levels (0.16 and 0.2 J). This study examined the effects of Ho:YAG laser on articular cartilage and subchondral bone in terms of depth of damage and healing response over time in a weight-bearing model. Additional research to define dose-response curves for Ho:YAG laser treatment of cartilage and subchondral bone are indicated.

John B. McGinty, editor. Philadelphia: Lippincott Williams and Wilkins; 2003. 995 pages. $299.00. Textbooks that contain information as timely as that found in a peer-reviewed journal are rare. This textbook is one such instance. It provides important information that is needed by today's practicing orthopaedic surgeons and that would not otherwise be easily accessed. Indeed, the textbook mode of information transfer has given these authors …

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.

Ten cases diagnosed as epidermoid carcinoma arising in the sinus tracts of chronic osteomyelitis have been reviewed. In two cases there were histologically proved metastases. Attention has been called to the signs and symptoms associated with carcinomatous change. The investigation of such a patient includes roentgenographic study of the limb and chest and a search for metastases in the regional lymph nodes and liver. A biopsy will guide the management. The histological diagnosis may be difficult because of pre-existing and coexisting metaplasia and pseudoepitheliomatous hyperplasia, which simulate cancer. The benign group should have extirpation of the sinus tracts and eradication of the osteomyelitis. Patients with atypical pseudoepitheliomatous hyperplasia and epidermoid carcinoma should have amputation at an adequate level and biopsy of suspicious regional lymph nodes. None of the three deaths in this series could be attributed to epidermoid carcinoma arising in osteomyelitis.

Acute avulsion of the bony attachment of the lateral capsular ligament was observed on x-ray films in September 1975. Seven instances were confirmed at surgery during the following 29- month period. The avulsion was reproduced in six amputation specimens which were dissected to identify the components of the lateral capsular complex. Dynamic studies were performed on a set of amputation specimens to determine the role of the various structures contributing to lateral rotary instability. The dissection revealed that the lateral capsular ligament complex has vertical and horizontal components. The dynamic studies showed that lateral pivot shift was produced by a lateral capsular release, a complete section of the anterior cruciate ligament, and a partial tibial collateral ligament release. Based on these observations, 30 patients have subsequently had re constructive surgery to eliminate their lateral rotational insta bility. In the reconstructive procedure, both the bony attach ment of the lateral capsular ligament and the iliotibial tract with Gerdy's tubercle have been moved anteriorly and inferiorly without separating their interconnections or any attachments. Clinical experience in these 30 patients supports the evidence obtained in the dynamic studies. Restoration of stability is secure when both the lateral capsular ligament and the iliotibial tract are advanced with their anatomical connections intact.

Important technical requirements for the successful use of the Holt nail are outlined. Emphasis was placed upon obtaining and maintaining a good reduction of the fracture with special attention given to the integrity of the calcar femorale. The Holt nail provided an excellent means of treating base-of-the-neck fractures and simple intertrochanteric fractures. This method was satisfactory in treating comminuted intertrochanteric fractures. Early weight-bearing was possible with all of the three types of fractures. There was no advantage in utilizing a Holt nail over other types of nails in treating comminuted subtrochanteric femoral fractures. The highest incidence of implement complication was in this group. Minimum migration of the nail was observed in all patients as impaction occurred with weight-bearing. Penetration was a complication in 8 per cent of patients. No fracture of the nail was observed, but fracture of the bolts occurred in nine patients. Measures to prevent these complications were discussed. There were thirteen surgical infections, and the mortality rate was similar to that of other series. The advantages of early weight-bearing were discussed.

AN OPEN-shoulder spica has provided a satisfactory means of managing several conditions previously requiring the traditional full spica (Fig 1). A combination of a waistband and a long arm cast connected with a wooden and plaster outrigger was first applied to an adult patient who was unwilling to remain in the traditional spica following a shoulder fusion. He had torn his plaster down in order to maintain his skin hygiene and to gain comfort. The open-shoulder spica was designed as a compromise, but it maintained the desired position until union was achieved. This spica cast has since been satisfactorily used to maintain the desired position in patients undergoing shoulder fusion, derotational humeral osteotomy, soft-tissue release with tendon transfer around the shoulder (L'Episcopo-Zachary procedure), and following reconstruction of a posterior dislocation of the shoulder. An open-shoulder spica has the following advantages: (1) simple application, (2) easy and accurate positioning, (3) light

Arthroscopy has had a great impact on shoulder surgery by adding another dimension to the surgical anatomy. The present benefits of arthroscopy of the shoulder include the establishment of an accurate diagnosis in the glenohumeral joint, subacromial space, and acromioclavicular joint. Various pathologic entities can be visualized. The efficacy and end results of several arthroscopic surgical procedures are under investigation. Patient selection, the pathologic diagnosis, and end results are important considerations in evaluating newly devised arthroscopic methods of treatment of shoulder syndromes.

This study explores the impact of a careful analysis of 1000 consecutive cases of diagnostic arthroscopy conducted by the author. The cases are evaluated to determine whether there is a tendency to clinically misdiagnose certain lesions. The findings furthered knowledge in regards to other possible diagnoses for specific symptom complexes. Diagnostic arthroscopy has allowed surgeons to " fine tune" their preoperative diagnostic ability and can be a very useful enhancement to the armamentarium of clinical evaluations, laboratory tests, plain radiographs, and double contrast arthrograms as diagnostic tools for knee problems. An "audit" procedure is outlined that could benefit any surgeon who is concerned about increasing their diagnostic ability.