a comparison between arthroscopic meniscectomy ... - Semantic Scholar

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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