[Accurate placement of bone tunnels in reconstruction of the anterior cruciate ligament - a contribution of computer-assisted navigation]

Rupture of the anterior cruciate ligament (ACL) is one of the most frequent injuries to the knee joint in the young. ACL repair is a major orthopedic procedure most often performed in the younger adult population. Early stabilization of the knee joint by ACL reconstruction also decreases the risk of injury to other important structures. At ACL reconstruction, the biggest problem is usually the exact placement of drilled tunnels. This significantly affects the outcome of surgery, i. e., range of motion, knee joint stability, reaction of the synovium in the knee, pain, impingement and potential graft failure with lesion development. However, 70 % of ACL reconstructions are carried out by orthopedic surgeons whose experience is limited to less than 20 ACL repair procedures in a year! Arthroscopy does not allow the surgeon to gain a complete 3D view of important anatomical structures, particularly in the anteroposterior direction. Computer-assisted navigation systems should aid in minimizing these problems. First reports on the use of computer-assisted navigation in ACL reconstruction, which have already been published in the international literature, have provided clear evidence that more exact bone tunnel placement can be achieved with navigation than with the use of conventional techniques. In addition, kinematic navigation enables us to measure anteroposterior and rotational knee stability, isometry, impingement and the angles of bone tunnel placement. It permits a choice from various types of graft. Last but not least, kinematic navigation provides a tool for recording surgery outcomes without a necessity to use further examination methods. Its drawbacks, namely, the learning curve, additional fixation of navigation probes to the femur and tibia and slightly longer operative time, should be considered in the context of presumed long-term benefits for the patient.

Age at menarche: Influences of prenatal and postnatal growth

OBJECTIVE

The objective of this study was to determine the influence of birth weight and postnatal weight gain on age at menarche.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective cohort study where girls from the West Australian Pregnancy (Raine) Cohort Study were followed prospectively from fetal life (18 wk of pregnancy) to adolescence (12-14 yr).

MAIN OUTCOME MEASURE

Age at menarche was the main outcome measure.

RESULTS

Growth status at birth was judged by expected birth weight ratio (EBW; a ratio of observed infant's birth weight over median birth weight appropriate for maternal age, weight, height, parity, infant sex, and gestational age). Postnatal growth status was judged by body mass index (BMI). Both EBW (P = 0.020) and BMI in childhood (8 yr of age) (P < 0.001) were associated with age at menarche. Menarche occurred earlier in girls with lower EBW and higher BMI.

CONCLUSIONS

We have demonstrated for the first time that both birth weight and weight gain in childhood are associated with age at menarche. Weight gain before birth and subsequent weight gain up to the age of 8 yr were found to have opposing influences on the timing of menarche. Lower EBW combined with higher BMI during childhood predicted early age at menarche, and this relationship existed across normal birth weight and BMI ranges.

[Consequennce of nontreatment scapholunate instability of the wrist]

Authors evaluate the results of patients with acute rupture of the scapholunate (SL) ligament, demonstrated by arthroscopy, in this study. One group of patients was treated with reinsertion of SL ligament by the help of Mitek anchor. In the other group there were patients with diagnosed total rupture of SL ligament which rejected the reinsertion of the ligament. Authors evaluate results of both groups 24 months after the injury. On the basis of clinical and X-ray results, even after such short time, reasonably worse results for the group without performed reinsertion were determined. Even X-ray documented arthrotic changes of scapholunate advanced collapse (SLAC) type were present.

Mood state and psychological adjustment to pregnancy

The aim of this study was to investigate whether there is an association between antenatal mood state (depression and anxiety) and psychological adjustment to pregnancy. Participants were first-time, low obstetric risk mothers at a Sydney teaching hospital who completed self-report questionnaires measuring depression, anxiety, thoughts about motherhood and self as mother and relationship with the fetus. Higher symptom levels of antenatal anxiety were related to less optimal maternal-fetal quality of attachment, more negative attitudes towards motherhood and the self as mother. Similar trends were found for symptoms of depression, however depression was not significantly related to psychological adjustment to pregnancy variables. The significance of anxiety in the current study highlights the importance of considering anxiety in the psychological adjustment to pregnancy, as well as the in the context of perinatal mental health more generally. Implications of these findings for intervention are also briefly discussed.

[Defect of the femoral condyle in the knee after patellectomy. Long-term results of fresh massive osteochondral allografting]

The presence of a massive full-thickness osteochondral defect in the knee of young and active individuals is an unsolved problem in orthopedic surgery, especially in post-traumatic large bone defects. Fresh massive osteochondral allografts have been used for many years but mostly in oncology but not in post-traumatic cases. This case report describes a 20-year-old right leg-dominant woman, who, at age 19, sustained open Gustilo-Anderson type III comminuted fractures of the left patella and lateral femoral condyle in a motorbike accident. Initial treatment included immediate débridement and patellectomy with lavage. The large defect of the femoral condyle was reconstructed with a massive osteochondral allograft 1 year after the injury. The graft was obtained from our institutional tissue bank. The damaged bearing part of the condyle was resected to bleeding bone to create the nearly rectangular defect. The central condyle wall remained intact. The graft was trimmed to fit the defect and fixed with three cancellous 6.5-mm screws. The meniscus was not damaged. Partial weight bearing was permitted at 8 weeks and full weight bearing at 16 weeks after the surgery. At the last follow-up control 10 years after the surgery, no evidence of tibiofemoral arthrosis was present. The allograft-host interface was not visible. The radiodensity of the graft was nearly identical to the host bone. The Lysholm score and clinical findings were identical (100 points) to those 18 months after the surgery. The patient was extremely satisfied without complaints at 30 years of age.

[Our experience with an image guided navigation system for accurate alignment in total hip replacement by minimally invasive posterolateral surgery]

PURPOSE OF THE STUDY

The aim of the study was to compare a radiographic position of the acetabular component with a position guided by the navigation system in final acetabular cup alignment.

MATERIAL

Between May and October 2005, 15 patients underwent implantation of a cementless acetabular component from the posterolateral minimally invasive approach with the use of kinematic navigation.

METHODS

The final acetabular cup alignment was determined from the data saved in the navigation system. The radiographic measurement of acetabular cup inclination was made from an anteroposterior projection of both hips on one image, and anteversion was determined by the Ackland method.

RESULTS

The average values for inclination and anteversion shown on radiographs were 41.8 degrees (range, 35-51) and 19.8 degrees (range, 5-32), respectively. The average values of cup alignment recorded at implantation by the navigation system were 27.6 degrees (range, 22-35) for inclination and 24.3 degrees (range, 17-28) for anteversion.

DISCUSSION

The acetabular cup alignment is considered optimal when inclination is 45 degrees and anteversion 15 degrees. This is more difficult to achieve in minimally invasive surgery due to a limited view of the operating field. This disadvantage can be overcome by using various navigation systems the function of which depends on the accuracy of recorded data.

CONCLUSIONS

Because the data recorded by the system used in our study were not accurate, we do not consider the OrthoPilot navigation system to be an effective aid in minimally invasive posterolateral surgery.

Adding a length scale to the polyamorphic ice debate

X-ray scattering and molecular dynamics simulations have been used to correlate the short range oxygen-oxygen structure with the intermediate range ordering (IRO) upon annealing very high density amorphous ice. While it is clear that the IRO that defines the network structure breaks down continuously to a minimum level, where there are weakened correlations extending beyond 7 Angstrom, at this point the local structure (O-O-O angles) is observed to change abruptly, allowing a continuous reemergence of a new IRO network. This is very different from a classic first order transition and helps reconcile previous data.

Functional characterization of the Bcl-2 gene family in the zebrafish

Members of the Bcl-2 protein family control the intrinsic apoptosis pathway. To evaluate the importance of this family in vertebrate development, we investigated it in the zebrafish (Danio rerio). We found that the zebrafish genome encodes structural and functional homologs of most mammalian Bcl-2 family members, including multi-Bcl-2-homology (BH) domain proteins and BH3-only proteins. Apoptosis induction by gamma-irradiation required zBax1 and zPuma, and could be prevented by overexpression of homologs of prosurvival Bcl-2 family members. Surprisingly, zebrafish Bax2 (zBax2) was homologous to mammalian Bax by sequence and synteny, yet demonstrated functional conservation with human Bak. Morpholino knockdown of both zMcl-1a and zMcl-1b revealed their critical role in early embryonic zebrafish development, and in the modulation of apoptosis activation through the extrinsic pathway. These data indicate substantial functional similarity between zebrafish and mammalian Bcl-2 family members, and establish the zebrafish as a relevant model for studying the intrinsic apoptosis pathway.

Case report of failed tubal occlusion using Essuretm pbc (permanent birth control) hysteroscopic sterilisation procedure

The device previously known as STOP, now called the Essure pbc device, is a dynamic expanding microinsert, placed in the proximal section of the fallopian tube, occluding the tube. Initial reports about the device are promising with occlusion of the tubes in 100% with no reported pregnancies and a high rate of safety and patient acceptability. This report documents the first reported failure of tubal occlusion of an appropriately placed Essure pbc device.

The effect of small intramural uterine fibroids on the cumulative outcome of assisted conception

BACKGROUND

This study aimed to evaluate the effect of small intramural fibroids on the cumulative pregnancy, ongoing pregnancy, live birth and implantation rates after three IVF/ICSI attempts.

METHODS

The first three treatment cycles of women enrolled for IVF/ICSI over a 12-month period were analysed. Only patients with small (<or=5 cm) intramural fibroids not encroaching upon the endometrial cavity were included in the fibroid group. Cox's hazards regression was used to estimate the hazard ratio (HR) associated with the presence of intramural fibroids.

RESULTS

During the study period, 322 women without fibroids (control group) and 112 women with fibroids (study group) underwent 606 IVF/ICSI cycles. The pregnancy, ongoing pregnancy and live birth rates in the study group were 23.6, 18.8 and 14.8% compared with 32.9, 28.5 and 24% in the control group, respectively (P<0.05). Cox regression analysis showed that the pregnancy rate at each cycle was reduced by 39% (HR=0.61, 95% CI=0.39-0.95, P=0.029) in the study group compared with the control group. The cumulative ongoing pregnancy rate was reduced by 43% (HR=0.57, 95% CI=0.35-0.91, P=0.018), and the cumulative live birth rate was reduced by 47% (HR=0.53, 95% CI=0.32-0.87, P=0.013) in the study group. After adjusting for confounding variables, the presence of fibroids was found to significantly reduce the ongoing pregnancy rate at each cycle of IVF/ICSI by 40% (HR=0.60, 95% CI=0.36-0.99, P=0.048) and the live birth rate at each cycle by 45% (HR=0.55, 95% CI=0.32-0.95, P=0.03).

CONCLUSION

Small intramural fibroids are associated with a significant reduction in the cumulative pregnancy, ongoing pregnancy and live birth rates after three IVF/ICSI cycles.

Trastuzumab and vinorelbine or taxane chemotherapy for HER2+ metastatic breast cancer: The TRAVIOTA study

650

Background: The optimal trastuzumab/chemotherapy regimen for advanced breast cancer is not known. We performed a multicenter, randomized clinical trial to compare TRastuzumab And VInorebline Or TAxane (TRAVIOTA) chemo- and bio-therapy combination treatment given on a weekly schedule for HER2+ metastatic breast cancer. Patients and Methods: Eligible patients had stage IV breast cancer, measurable disease (by RECIST criteria), HER2+ tumors (IHC 3+ or FISH+), no prior chemotherapy or trastuzumab for advanced breast cancer, and LVEF > 50%. Patients were randomized 1:1 to trastuzumab (4 mg/kg loading dose, 2 mg/kg weekly thereafter) with either weekly vinorelbine (25 mg/m2) or weekly taxane (paclitaxel 80 mg/m2 or docetaxel 35 mg/m2, selected by the treating investigator). The primary endpoint was response rate. The study opened in August 2001 and planned to accrue 250 patients. It was closed in December 2003 having accrued only 85 patients. Results are presented for the 81 patients who received any protocol-based therapy. Results: Patients receiving trastuzumab and vinorelbine tended to have higher response rates and TTP than those assigned trastuzumab and taxane therapy but the results were not statistically significant (see Table ). Vinorelbine therapy was associated with more frequent grade 3 or 4 hematological toxicity and dose delay because of myelosuppression. Other toxicities generally reflected the known side effects of the chemotherapy agents. Conclusions: The TRAVIOTA study suggests at least comparable clinical activity of trastuzumab with vinorelbine as with weekly taxane chemotherapy in HER2+ metastatic breast cancer, with side effect profiles consistent with previous experience with these regimens.

[Table: see text]

[Table: see text]

Polycystic ovarian syndrome--prognosis and outcomes

Polycystic ovarian syndrome (PCOS) is a condition that is present in 5-6% of women of reproductive age. It has potentially profound implications for women with regard to anovulatory infertility and symptoms related to elevated androgen levels. In addition, in later life women are prone to significant health problems related to hyperinsulinaemia, with an excess risk for diabetes and cardiovascular risk factors. Evidence suggests that the adverse features of PCOS can be ameliorated with lifestyle intervention, such as diet and exercise, while further short-term benefits related to ovulation and cardiac risk factors may be derived from medication with metformin. Evidence for the long-term use of metformin to protect against adverse cardiovascular outcomes and for the use of metformin throughout pregnancy to reduce the risk of miscarriage, gestational diabetes, pre-eclampsia and fetal macrosomia is still lacking.

Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial

BACKGROUND

Oral anticoagulation therapy reduces risk of vascular events in patients with atrial fibrillation. However, long-term monitoring is necessary and many patients cannot achieve optimum anticoagulation. We assessed whether clopidogrel plus aspirin was non-inferior to oral anticoagulation therapy for prevention of vascular events.

METHODS

Patients were enrolled if they had atrial fibrillation plus one or more risk factor for stroke, and were randomly allocated to receive oral anticoagulation therapy (target international normalised ratio of 2.0-3.0; n=3371) or clopidogrel (75 mg per day) plus aspirin (75-100 mg per day recommended; n=3335). Outcome events were adjudicated by a blinded committee. Primary outcome was first occurrence of stroke, non-CNS systemic embolus, myocardial infarction, or vascular death. Analyses were by intention-to-treat. This study is registered with ClinicalTrials.gov, number NCT00243178.

RESULTS

The study was stopped early because of clear evidence of superiority of oral anticoagulation therapy. There were 165 primary events in patients on oral anticoagulation therapy (annual risk 3.93%) and 234 in those on clopidogrel plus aspirin (annual risk 5.60%; relative risk 1.44 (1.18-1.76; p=0.0003). Patients on oral anticoagulation therapy who were already receiving this treatment at study entry had a trend towards a greater reduction in vascular events (relative risk 1.50, 95% CI 1.19-1.89) and a significantly (p=0.03 for interaction) lower risk of major bleeding with oral anticoagulation therapy (1.30; 0.94-1.79) than patients not on this treatment at study entry (1.27, 0.85-1.89 and 0.59, 0.32-1.08, respectively).

CONCLUSION

Oral anticoagulation therapy is superior to clopidogrel plus aspirin for prevention of vascular events in patients with atrial fibrillation at high risk of stroke, especially in those already taking oral anticoagulation therapy.

Rationale and design of ACTIVE: the atrial fibrillation clopidogrel trial with irbesartan for prevention of vascular events

BACKGROUND

Atrial fibrillation (AF) is the most frequently occurring cardiac arrhythmia with often serious clinical consequences. Many patients have contraindications to anticoagulation, and it is often underused in clinical practice. The addition of clopidogrel to aspirin (ASA) has been shown to reduce vascular events in a number of high-risk populations. Irbesartan is an angiotensin receptor-blocking agent that reduces blood pressure and has other vascular protective effects.

METHODS AND RESULTS

ACTIVE W is a noninferiority trial of clopidogrel plus ASA versus oral anticoagulation in patients with AF and at least 1 risk factor for stroke. ACTIVE A is a double-blind, placebo-controlled trial of clopidogrel in patients with AF and with at least 1 risk factor for stroke who receive ASA because they have a contraindication for oral anticoagulation or because they are unwilling to take an oral anticoagulant. ACTIVE I is a partial factorial, double-blind, placebo-controlled trial of irbesartan in patients participating in ACTIVE A or ACTIVE W. The primary outcomes of these studies are composites of vascular events. A total of 14000 patients will be enrolled in these trials.

CONCLUSIONS

ACTIVE is the largest trial yet conducted in AF. Its results will lead to a new understanding of the role of combined antiplatelet therapy and the role of blood pressure lowering with an angiotensin II receptor blocker in patients with AF.

The value of virtual reality–simulator training in the development of laparoscopic surgical skills

OBJECTIVE

To determine the effectiveness of virtual reality (VR) training in improving the surgical skills of medical students and gynecologic trainees.

DESIGN

A prospective observational study to assess the changes observed in objectively measured surgical performance after VR training.

SETTING AND POPULATION

University teaching hospital and the laboratories of the University of Western Australia.

PARTICIPANTS

Fifteen 5th-year medical students, six junior-doctor trainees (years 1-3), and eight senior trainees (years 4-6).

INTERVENTIONS

Standard gynecologic procedures before and after VR training were undertaken on sheep. The procedures were video-recorded and edited to blind the scorer as to identity and seniority of the operator. The procedures were scored using a combination of operative time and penalties for surgical errors. The surgical scores were correlated with the VR scores.

MEASUREMENTS AND MAIN RESULTS

Operative skills were assessed using a combination score compiled from scores obtained while undertaking salpingectomy, salpingotomy, and tubal clipping. Virtual reality scores were also a combination score derived from summation of various computer-calculated measures of time and accuracy in undertaking two standardized exercises.

RESULTS

The baseline VR scores were significantly related to the overall pre-training scores (salpingectomy p = .032). A better initial VR score was also predictive of better surgical performance. The initial VR score was also predictive of improvement observed between baseline and post-training (p = .004).

CONCLUSION

Virtual reality training is of value in improving surgical skills in the clinical environment. It appears to be of most value in the earliest stages of training. These data suggest that serious consideration should be given to incorporating VR training into the training program of obstetricians and gynecologists at an early stage.

Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks

BACKGROUND

Non-valvular atrial fibrillation (AF) carries an increased risk of stroke. Antiplatelet therapy (APT) is proven effective for stroke prevention in most patients at high-risk for vascular events, but its value for primary stroke prevention in patients with non-valvular AF merits separate consideration because of the suspected cardioembolic mechanism of most strokes in AF patients.

OBJECTIVES

To assess the efficacy and safety of long-term APT for primary prevention of stroke in patients with chronic non-valvular AF.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (searched August 2004). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to June 2004), and the reference lists of recent review articles. We also contacted experts working in the field to identify unpublished and ongoing trials.

SELECTION CRITERIA

Randomized trials comparing long-term APT with placebo or control in patients with non-valvular AF and no history of transient ischemic attack (TIA) or stroke. A sensitivity analysis included one additional randomized trial involving primary prevention with aspirin plus very low dose warfarin.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion and extracted data for each outcome. Unpublished data were obtained from trial investigators.

MAIN RESULTS

Three trials tested aspirin in dosages ranging from 75 mg to 325 mg per day and 125 mg every other day to placebo (in two trials) or control (in one trial) in 1965 AF patients without prior stroke or TIA. The mean duration of follow up averaged 1.3 years per participant. Aspirin was associated with non-significant lower risks of all stroke (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.47 to 1.07), ischemic stroke (OR 0.70, 95% CI 0.46 to 1.07), all disabling or fatal stroke (OR 0.86, 95% CI 0.50 to 1.49) and all-cause death (OR 0.75, 95% CI 0.54 to 1.04). The combination of stroke, myocardial infarction or vascular death was significantly reduced (OR 0.71, 95% CI 0.51 to 0.97 ). No increase in intracranial hemorrhage or major extracranial hemorrhage was observed.

AUTHORS' CONCLUSIONS

Aspirin appears to reduce stroke and major vascular events in patients with non-valvular AF similar to its effect in other high-risk patients (ie by about 25%). For primary prevention among AF patients with an average stroke rate of 4% per year, about 10 strokes would likely be prevented yearly for every 1000 AF patients given aspirin.

[Benefits of the computer navigation for reconstruction of the anterior crutiate ligament of the knee joint]

AIM

The aim of this work is a radiological assessment of accuracy of the osseous channels location in initial reconstructions of the anterior crutiate ligament (PZV) conducted using a navigation system.

METHODOLOGY

Following arthroscopic preparation of the joint space and registration of the essential data, conducting wires for channels in tibia and femur are navigated using the navigation system. The lig. patellae graft is then pulled-through and fixed using interference screws. The channels location was assessed using radiological methods according to Bernard-Hertel and Harner.

RESULTS

A correct emergence of the femoral channel was found in 13 (87%) and of the tibial channel in 14 (93%) cases. The optimum graft location with respect to the both osseous channels was detected in 12 knee joints (80%).

CONCLUSIONS

Exact location of the osseous channels is a principal prerequisite for a good result of the anterior crutiate ligament reconstruction. In case of standard procedures, this may be possible only in case the operating surgeon conducts a large number of reconstructions every year. In daily practice, however, 70% of reconstructions are conducted by less experienced orthopaedic surgeons. Our initial results indicate that the navigation system could become an effective tool for the surgeons who do not have the opportunity for conducting the above procedures too often.

Excisional surgery versus ablative surgery for ovarian endometriomata: a Cochrane Review

BACKGROUND

The objective of this review was to determine which is the most effective technique for treating an ovarian endometrioma; excision or ablation.

METHODS

A systematic review employing the principles of the Cochrane Menstrual Disorders and Subfertility Group was undertaken. No randomized studies of the management of endometriomata by laparotomy were found. Two randomized studies of the laparoscopic management of ovarian endometriomata of >3 cm in size were included.

RESULTS

Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced rate of recurrence of the endometrioma [odds ratio (OR) 0.41, confidence interval (CI) 0.18-0.93], reduced requirement for further surgery (OR 0.21, CI 0.05-0.79), reduced recurrence rate of the symptoms of dysmenorrhoea (OR 0.15, CI 0.06-0.38), dyspareunia (OR 0.08, CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10, CI 0.02-0.56). It was also associated with a subsequently increased rate of spontaneous pregnancy in women who had documented prior subfertility (OR 5.21, CI 2.04-13.29).

CONCLUSIONS

There is some evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation, with regard to the recurrence of the endometrioma, recurrence of symptoms and subsequent spontaneous pregnancy in women who were previously subfertile. Consequently this should be the favoured surgical approach. However, we found no data to indicate the best surgical approach in women planning to undergo assisted reproductive techniques.

Radiological study of tha after mini-incision technique

Mini-incision procedures reduce perioperative blood loss, postoperative pain, time of the postoperative recovery, length of the surgical scar, and hospitalisation time. Implant malposition and poor stability are potential risks for compromising long-term results. Between September 2000 and February 2002 (18 months), 120 cemented primary total hip arthroplasties for primary osteoarthritis were performed at the authors institutions. In 60 of these cases selected at random, a posterolateral mini-incision up to 10 cm was used. Sixty other THAs were implanted through a standard posterolateral approach. The radiological measurements of the inclination and anteversion of the cup and stem position were performed and statistically evaluated by use of Mann-Whitney U and Bartlett tests. In the mini-incision group the average inclination angle was 42.3 (range 36 to 52) and the anteversion angle 13.6 (range 6 to 21). The femoral component coronal alignment was within 3 of neutral position in 54 cases (90.0 %). In the standard implanted group the average cup inclination angle was 42.4 (range 35 to 50) and anteversion angle 13.6 (range 8 to 24). Fifty-three stems (88,3 %) were implanted correctly. Statistical analysis found no significant difference in component position between the two groups. There are therefore no potential risks of compromising long-term results after the mini-incision procedure. The authors are encouraged to continue this technique. (Hip International 2005; 15: 98-101).

[Correlation of long-term clinical and radiological results after meniscectomies]

PURPOSE OF THE STUDY

Although surgical treatment of meniscus injuries has made great progress, meniscectomy remains the most frequently indicated intervention. The aim of this retrospective study was to evaluate the long-term radiological results of isolated subtotal and total meniscectomies and compare them with the clinical results.

MATERIAL

The assessed group included 22 men and 8 women at an average age of 35 years; nine and 21 knees, respectively, were treated by isolated subtotal and total meniscectomy in the period from 1987 to 1989. The lateral meniscus was operated on in six knees and the medial meniscus in 24 knees. Patients with other injuries to the knee joint or with a systemic disease were not evaluated. The average follow-up was 16 years. The results were compared with the other, non-treated knee.

METHODS

The results were assessed by means of the Lysholm scoring system which takes into account limping, support requirement, walking distances, instability, edema, stair ascent and descent, ability to squat and pain. Radiographic osteoarthritis of the knee was classified by the Kellgren and Lawrence system. A grade greater or equal to 2 was taken for a clear sign of arthritis. In addition, the anatomical axis of the lower extremity was evaluated. Anteroposterior projection of both knees under load was made in a standing position on long films and lateral projection was obtained separately on short films.

RESULTS

The average Lysholm scores were 87 points (range, 41-100) and 91 points (range, 67-100) in the treated and non-treated knees, respectively. The outcome of meniscectomy was excellent in 14 (47 %), good in eight (27 %), satisfactory in five (16 %) and poor in three (10 %) knees. In 12 patients (40 %) the state of the treated knee was evaluated as being equal to that of the non-treated knee and in eight patients (27 %) it was even better. Osteoarthritis of the affected compartment was found in eight treated knees and that of the corresponding compartment on the opposite side in four knees. Grade 2 Kellgren- Lawrence radiographic changes were present in four, grade 3 in two and grade 4 in two knees treated by meniscectomy. The anatomic femoro-tibial angle differed between the treated and non-treated side, by 4 degrees on average (range, 2 degrees to 10 degrees ), in 13 (43 %) patients.

DISCUSSION

Johnson et al. found at follow-up for about 17 years that osteoarthritis developed more often in the treated than in healthy contralateral knees (40 % as against 6 %). Tapper and Hoover reported that 45 % of men and 10 % of women were without subjective complaints at 10 to 30 years of follow up. In the relevant Czech literature, only Pasa et al. have recently paid attention to the development of lesions in knees treated by meniscectomy, but they have largely evaluated changes occurring after partial arthroscopic meniscectomies.

CONCLUSIONS

The present study showed that osteoarthritis after subtotal or total meniscectomy developed in 27 % of the patients at an average follow-up of 16 years. In less than half of the patients, a deviation of the anatomical axis occurred in the treated lower extremity, as compared with the other healthy side. Lysholm scores worse in the treated than the non-treated knee were found in one third of the patients.However, a deviated knee joint axis and/or osteoarthritic lesions did not always correlate with deteriorated clinical findings.

[Arthroscopy of the hip joint]

PURPOSE OF THE STUDY

Arthroscopic examination of joints has recently gained wide application. Due to hip joint shape and a difficult approach to it, hip arthroscopy has long remained outside the attention and abilities of arthroscopists. The authors present their first experience with operative hip arthroscopy that offers new options for the treatment of intra-articular pathology of the hip joint.

MATERIAL

In the years 2001-2003, 24 hip arthroscopies were performed. The following pathological conditions were diagnosed and treated: loose bodies, chondral lesions of the femoral head and acetabulum, ruptures of the labrum acetabuli and ligamentum teres, impingement syndrome of the labrum acetabuli, and coxitis. No post-operative neurologic symptoms or vascular complications were observed.

METHODS

All procedures were carried out on patients in a supine position, with the treated joint in traction. A standard 30 degrees device and common instruments for arthroscopic surgery were used. The instruments were inserted in the articular fissure with the use of an X-ray intensifier. Movement in the hip joint during surgery is very limited due to traction, joint shape and the length of working canals. After traction is released, it is possible to examine also the intra-articular part of the femoral neck.

RESULTS

The pre-operative complaints (clunking, painful joint) were relieved up to 4 to 6 weeks after surgery in 23 patients. In one patient primarily diagnosed with coxitis, infection was not eradicated after lavage and debridement and, because inflammation deeply affected the femoral head, the hip was eventually treated by Girdlestone arthroplasty. The results were evaluated clinically and on the basis of the Merle d'Aubigne and Postel questionnaire assessing pain and walking abilities by both the patients and the surgeon. All 24 patients reported poor or average conditions before surgery and, after surgery, 23 experienced improvement to a very good or average condition. One patient's state failed to improve and was evaluated as poor both before and after surgery.

DISCUSSION

Hip arthroscopy is a minimal invasive technique which allows us to diagnose and, at the same time, treat intra-articular pathology in a gentle manner. In arthroscopic surgery, correct diagnosis (X-ray, CT and MRI), correct patient's position, their body mass (obesity), selection of appropriate approaches to the joint, surgeon's experience and potentials of arthroscopic instruments all play an important role. We assume that, with increasing experience, the number of patients as well as the scope of diagnosed and treated pathological conditions of the hip joint will grow. The outcomes of operative arthroscopy were very good (improvement in 23 of 24 patients) and it is probable that this technique can slow down or prevent early wear-and-tear hip arthritis.

CONCLUSIONS

In our country, operative arthroscopy of the hip is only at its beginning. However, it can be assumed that, similarly to other large joints, it will soon become a widely used, indispensable diagnostic and therapeutic method.