meniscectomy. The best results of all, however, were those after partial arthroscopic meniscectomy. Meniscal lesions are common and arthroscopy is a well-.
A COMPARISON
BETWEEN MODIFIED
A PROSPECTIVE
ARTHROSCOPIC MENISCECTOMY OPEN MENISCECTOMY
RANDOMISED
PER
STUDY WITH REHABILITATION
HAMBERG,
From
JAN
EMPHASIS
GILLQUIST.
the University
JACK
Hospital,
ON
AND
POSTOPERATIVE
LYSHOLM
LinkOping
is now well established
as a method of diagnosing meniscal lesions, and its advantages have reports. Arthroscopic surgery, however, is difficult to master, so that for open methods remain commoner. By taking advantage of the new instruments and equipment developed for arthroscopic operations, a modified technique of open meniscectomy, designed to improve the postoperative course, has been developed. In a prospective randomised study, the results after this modified open meniscectomy were comparable with those obtained after arthroscopic operation and were significantly better than those after conventional meniscectomy. The best results of all, however, were those after partial Arthroscopy
been pointed meniscectomy
out
arthroscopic Meniscal
meniscectomy.
lesions
established
are common
method
Hagberg
1976;
and
arthroscopy
of diagnosing
Jackson
Gillquist,
1977;
in several
them
and
Hagberg
Dandy
and
is a well-
(Gillquist
1976;
Oretorp
and
O’Connor
1979;
Marvin
1977;
but also
after
Hamberg
Dandy total
and
scopic
flap
tears
1978;
Oretorp
arthroscopic
Lyshoim
meniscectomy
(McGinty, and
1982).
The
is, however,
technique
the commonest
By taking equipment
we
designed
have
the same
now
standard
as after
or
total. course
of our
be removed
of arthro-
would
and
technique
with
and
arthroscope,
for
open
operation.
results
those
of
We
using our
that
walking
Our objective and bring it to
an arthroscopic
a comparison
open
the
informed
would
1979),
to master,
technique
was
(Gillquist,
instruments
with
study
was
prospective
on postoperative
MATERIAL
be done
not easy to obtain. meniscectomy re-
new
a modified
whether partial the postoperative
present
modified
of the
for operating
developed
meniscectomy, was to improve
and
method.
advantage
Our
emphasis
and
rehabilita-
this
standard
AND
METHODS
Patients with degenerative tears of the medial meniscus but with no history of previous injury or operation on the affected knee were selected. Before operation the patient could
Giliquist
difficult
the necessary guidance and practice In many countries, therefore, open mains
Geuss
meniscectomy
with
tion.
;
and
technique.
randomised,
Johnson
1981). In recent years several reports have described the advantages of using arthroscopic techniques for dealing with meniscal tears (O’Connor 1977; Gillquist 1980; Johnson 1981 Lysholm and Gillquist 1981). Good results have been reported especially after partial meniscectomy
for bucket-handle
arthroscopic
procedure
after
a minor
that
the
were
arthroscopy al. 1979)
el
one
torn
and that
after
taken
operation.
of both
(Gillquist and was performed
of a degenerative
which
meniscus
arthroscopy,
immediately
radiographs
diagnosis
was
diagnostic
be possible
Weight-bearing before operation. Diagnostic 1976; Gillquist clinical
the
as an outpatient,
knees
Hagberg once the
meniscal
tear
had
been made. When a horizontal cleavage or flap tear in the posterior horn of the medial meniscus had been confirmed, the patient was allocated by a table of random numbers to one of four different groups. There were 10 patients in each group and the methods of treatment were : (1) arthroscopic partial meniscectomy (2) arthro;
scopic
total
meniscectomy
; (3) open
partial
meniscec-
tomy or(4)open total meniscectomy. All meniscectomies were performed by one of three surgeons with long experience of arthroscopic and open operations. The intention was to treat all patients as outpatients ;
P. Hamherg,
MD.
J. Gillquist. J. Lvsholm.
Consultant
MD. Associate MD. Lecturer
Orthopaedic
Professor in Orthopaedic
Surgeon
Surgery
Sports Trauma Research (1 roup. Department of Orthopaedic University Hospital. 5-581 85 Linkoping, Sweden. Requests .
0301
VOl..
for reprints
I 984
British
620X
66-B.
84 2036
No.
should
Editorial
be sent
Society
52(8)
2. MARCH
to Dr P. l-Iamberg.
of’ Bone
and
Joint
Surgery
Surgery.
and
up for at least and
984
for them
all to have
the same
postoperative
treatment.
Rehabilitation was guided by a physiotherapist who also measured the muscle strength. Each patient was followednormal
eight physical
weeks
or until
they-
returned
to work
activity. I 89
190
P. HAMBERG,
Joint
stability
cartilage
were
factors symptoms,
and degenerative
recorded
at the
including sex, operating
postoperative
to physical
time
age, time,
of operation.
sick
fitness
leave,
also
were
and
1982).
( 1 5),
This
support
( 10),
swelling
system
assesses
(5), giving and
way
and the results scores of 77
were judged to 90 had
before
operation
limp
to climb
stairs
(10)
and
of the thigh one,
four
Below or
and
eight
or
total,
are
also
diagnostic
evaluation.
tourniquet
inflated,
performed
The and
the
whether
par-
immediately
arthroscope
after
is removed,
surgeon
is
changes
his
the gown
through an the knee in
stress applied with the to see right back to the
scissors.
Total
poor
muscles
tial
the joint
posterior horn ofthe medial meniscus. Extra light can be brought into the posterior part of the joint by using the light cable for the arthroscope. Partial meniscectomy can be done with instruments designed for arthroscopic operations, such as basket forceps, a Stille knife and
and
Patients with on vigorous
to be moderate. to be fair
At the end of all arthroscopic meniscectomies cleared of debris by aspiration. Open meniscectomy. Open meniscectomies,
20#{176} of flexion and under valgus mechanical leg-holder, it is easy
(25), catching
to be excellent. mild symptoms
and Gillquist 1981). strength. The strength
Muscle measured
criteria:
pain
J. LYSHOLM
and gloves. Open partial meniscectomy is performed anteromedial incision about 3 cm long. With
score was 95 points. Patients had no significant symptoms
physical activity and were judged 77 points patients were considered
(Lysholm
of
scale adapted knee function (Lysholm and
eight
(20),
the ability
to squat (5). The maximum with scores above 90 points
time
recorded.
The Lysholm point-scoring for meniscal lesions was used to evaluate before operation and eight weeks after (5 points),
Other
duration of in hospital,
Kneefunction.
Giliquist
in articular
occupation, time spent
attendances,
restoration
changes
J. GILLQUIST,
was weeks
incision meniscus is made
meniscectomy
also starts
with an anteromedial
(Smillie 1978). The anterocentral is mobilised using a Smillie’s knife. 2 to 3 mm from the meniscocapsular
part of the The incision junction.
after, using a Cybex II isokinetic dynamometer (Lumex, The meniscus is mobilised to the posteromedial corner, Bayshore, New York), at an angular velocity of 30#{176} per and a posteromedial incision about 3 cm long is made second, and also isometrically at a knee angle of 60#{176}.(Smillie 1978). The mobilised part of the meniscus is Muscle strength on the affected side was expressed as a pulled out through the second incision and held with percentage of that on the unaffected side. forceps the operation is completed by excising the Data analysis. The coefficient of variation for the score posterior horn, again using a Smillie’s knife. evaluation was ± 2.8%, and for the Cybex measurement Careful haemostasis is important in the open technique. The wound is closed in the conventional ± 1 3%. Knee function scores were analysed by Student’s t test for paired samples, and muscle torque values were manner. The sutures can be replaced by surgical tape after one week. treated by analysis of variance. Other data were treated ;
by the
Kolmogorov-Smirnofftest
and
and
inflated
always television
if necessary.
used, and camera
the on
A
the
Mann-Whitney
RESULTS
U test. Surgical technique. Arthroscopic or regional anaesthesia is used.
General is applied
meniscectomy.
A tourniquet mechanical
leg-holder
is
operation is usually done with a the arthroscope. Partial or total
arthroscopic meniscectomy is carried out immediately after diagnostic evaluation using the same arthroscope and the same positioning of the leg. Other instruments are introduced through portals medial or lateral to the arthroscope or into the posterior compartment. For partial
meniscectomy
a knife
used. The portion probed to check stability
of the
For technique
arthroscopic described
al.
( 1982)
is used.
and
The
and middle portions used for the posterior
After
extraction
is carefully abnormal
forceps
are
rim.
total meniscectomy by Gillquist (1980)
the one-piece and Giliquist et
meniscus
with
is excised
knife using five portals and four periphery ofthe meniscus. During ;
basket
of meniscus left in situ is carefully for further tears and to evaluate the
of the
meniscus
the
horn the 70#{176} telescope of the meniscus the small
checked with a probe tissue, which is removed
the special
to five incisions in the excision ofthe anterior
for with
30#{176} telescope
is
is necessary. capsular rim any remaining basket forceps.
Each of the four groups men. The mean age was In most patients (85%) symptoms and operation the time ofmeniscectomy
included one woman and nine similar in all groups (Table I). the interval between onset of was three months or more. At moderate degenerative changes
in the medial compartment were (35%) who were equally distributed
seen in 14 patients between the different
groups. Radiographs before operation showed slight joint-space narrowing on the medial side of the knee (Stage I according to Ahlb#{228}ck’sclassification, 1968) in only five patients (12.5%); in one ofthese no degenerative changes could be seen with the arthroscope. All patients were treated as outpatients except for two; one of these two was admitted to hospital for one day for observation because of known heart disease, the other, a 37-year-old policeman treated by open total meniscectomy, was kept in for four days because of pain and swelling. (This policeman was off work for 22 weeks because of slow recovery of quadriceps strength and the active nature of his job.) The operating time for arthroscopic partial meniscectomy was significantly shorter than for arthroscopic total meniscectomy (P < 0.01), for open total meniscectomy (P
