John Joyce Award Finalists

Arthroscopy: The Journal of Arthroscopic & Related Surgery Online

October 1999, Supplement 1 • Volume 15 • Number 7

<< Back to topic list

John Joyce Award Finalists Abstracts

° Previous article in Issue • Next article in Issue • Drug links from Mosby's DrugConsult • Genetic information from OMIM

These are the abstracts of the papers presented at the Second Biennial Meeting of The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine, Washington, DC, May 29- June 3, 1999.

18. First Metatarsophalangeal Joint Arthroscopy: An Anatomic Evaluation.

Tara Giorgin~ M.D. Gaetano Maresca Pau Gofano M ichele Calderaro

John Joyce Award Finalists

Purpose: To anatomically evaluate arthroscopy of the first metatarsophalangeal joint in cadaveric specimens. Materials and Method: In a fully-equipped arthroscopic anatomy laboratory, nine cadaveric first MPJ's were dissected at different stages of the arthroscopic procedure: three prior to portal entry, three after portal entry and three after arthroscopy. Portal entry was measured according to anatomic landmarks, and evaluated for risk of neurovascular damage. Examination views from each portal were evaluated arthroscopically, with sesamoid visualization through a plantar portal approach. Arthroscopic examination was compared to gross anatomic pathology.

http:ttw~2.us.elsevierhealth.com/inst/serve?n...tion=searchDB&group=J ohn+Joyce+Award+FinalisLs (1 or 6) [12/13t2007 11:59:21 AM]


Results: The dorso-lateral portal was anatomically evaluated to cause less neurovascular risk, and therefore should be made initially. Placement of the dorso-lateral portal was measured 0.5 cm lateral to the EHL tendon, distal to the first MPJ, and 2 cm proximal to the great toe sulcus. Placement of the dorsal-medial portal was measured 0.5 medial to EHL tendon, parallel to dorsal-lateral portal. The plantar medial portal was measured 2.5 medial to the dorsal-medial portal and 3 cm medial to the extensor tendon. All 13-points of examinations, according to Ferkel, were visualized utilizing the three portals. Sesamoid visualization was optimized with removal of joint distraction, slight plantarflexion of the hallux, and a more proximally angulated plantar-medial portal. Conclusion: First MPJ arthroscopy is a valid arthroscopic procedure as seen after cadaveric dissection and experimentation. Our anatomic study explains performing this procedure in a carefully selected group of patients with MPJ and sesamoid pathology, for example hallux rigidus, trauma, and/ or sports related injuries. Significance: Prior to any arthroscopy, especially the first metatarsophalangeal joint, a thorough knowledge of anatomy, procedure, and possible risk through cadaveric experimentation is necessary for future surgical application and success.

19. Results of Arthroscopic Excision of the Fragment in the Treatment of Osteochondritis Dissecans of the Knee.

Fabrizio Ponteggia, M.D. Paolo Agfietti, M.D. Antonio Ciardullo, M.D. Pietro DeBiase, M.D.


Purpose: To evaluate the clinical and radiological results of arthroscopic excision of the fragment and debridement of the crater in the treatment of Osteochondritis Dissecans of the Knee (OCD) in an unselected group of cases. Material: Twenty-two patients with OCD of the femoral condyles (19 medial, 3 lateral)in stage 3 or 4 according to Guhl's classification, were included in our study (6 female, 16 male). The average age was 22 years (12-32). The average area of the lesion was 4 square centimeter. The lesion was in a primary weight-bearing area (infero-central or extended classical position according to Aichroth) in 54% of the cases, while in 46% it was in a secondary weight-bearing area (classical position). Method: From 1982 to 1995 all the observed cases with clear demarcation of the fragment or loose body were treated arthroscopically by the same surgeon with removal of the fragment, curettage and drilling of the base of the crater to provoke bleeding from the subchondral bone and fibro-cartilaginous healing. Rehabilitation evolved in a 3 months period. The International Knee Documentation Committee (IKDC) form was used for clinical examination, grading subjective assessment, symptoms (pain, swelling, giving-way), range of motion and stability. Each parameter is defined as normal (grade A), nearly normal (grade B), abnormal (grade C) and severely abnormal (grade D); the final result is the worst achieved in the single categories. Radiographic evaluation (weight-bearing antero-posterior view in extension compared to preoperative and 45 ° of flexion postero-anterior view of both knees with the patient standing) was graded according to Fairbank-Ahlback criteria: Grade 0, no changes; Grade I, edge sharpening, formation of osteophytes, sclerosis and flattening, no joint space reduction; Grade

http://www2.us.elsevierhealth.com/inst/serve?n...tion searchDB&group John +Joyce+Award +Finalists (2 of 6) [12/13/2007 11:59:21 AM]

Arthroscopy: The Journal oi: Arthroscopic & Related Surgery Online

II, grade I plus narrowing of the joint space up to 50%; Grade III, grade I plus narrowing of the joint space over 50%. Results: All the patients were evaluated with an average follow-up of 6 years (2-13). The overall IKDC result was satisfactory (Grade A or B) in 82% of the cases. Subjective assessment was satisfactory in 86% of the cases and 18% of them complained of pain (Grade C). Three patients (14%) had to reduce activity due to knee problems. Radiographic examination showed two grades of worsening (from no degenerative signs in the preoperative examination to narrowing of the joint space up to 50%) in one patient (4,5%) while 32% of cases showed one grade of worsening. No patients had grade III. No statistical significant correlations between results and location or size of the lesion was found. Conclusions: The results seem to indicate that this technique may still be considered a valid option in the treatment of OCD: it is technically easy and without complications and the rehabilitation is short. Symptoms are relatively infrequent and moderate and the patients could return in general to the desired sports activities. We think that perhaps a longer follow-up is necessary to better understand the incidence of degenerative changes.

20. Intractable Hip Pain in the Young Competitive Athlete; Arthroscopic Findings and Treatment.

Joseph C. McCarthy, M.D. Frank Alusio, M.D.


Intraarticular disorders in young adult athletes are uncommon but can be disabling and career ending. Hip arthroscopy affords an opportunity to diagnose and treat intraarticular pathology. The purpose of this study was to arthroscopically define the pathology and associated treatment in young athletes with intractable hip pain. Twenty-two competitive athletes (25 hips) on the high school to professional level were referred to the senior author with intractable hip pain preventing them from continuing their sports. All had mechanical symptoms consisting of painful clicking, buckling and a sensation of subluxation. All had gradual atraumatic onset associated with their sports with pre-operative symptoms occurring for an average of 17.8 mos. (3-108) prior to referral for operative intervention. These athletes saw an average of 3 physicians prior to referral. Extraarticular and referred lumbar pathology were ruled out prior to hip arthroscopy. All patients underwent hip arthroscopy in the lateral position revealing anterior labral tears in 92% of cases with associated anterior acetabular chondral defects in 80%. Femoral head chondromalacia was noted in 6 cases (24%) with three of these having additional chondral defects. All three of the femoral head chondral defects had associated loose bodies. Both patients with pre-operative symptoms lasting greater than 3 years had larger chondral defects and degenerative changes which were more diffuse and pronounced than the others. This suggests that these lesions may predispose to early degenerative changes if left untreated for prolonged periods. Treatment involved debridement of the labral tears and chondral defects to stable healthy bases. The acetabular defects, if necessitating debridement to bone, had drilling to enhance fibrocartilage formation. All patients had improvement in pain and alleviation of mechanical symptoms with those having greater than six-month follow-up returning to their sports.



The intraarticular pathology defined in this study may be a potential result of repetitive axial loading in high torque positions associated with particular sports (soccer, hockey, martial arts). The anterior location of the labral tear/chondral defect complex may account for the subtle instability symptoms noted in these patients and may be a corollary to the Bankhart lesion of the shoulder. In conclusion this study identified the intraarticular pathology and associated treatment of intractable hip pain in competitive athletes, allowing those with adequate follow-up (> 6 mos.) to return to their sports.

21. Arthroscopic Subacromial Decompression: A 9-Year Follow Up.

Mark Hazel M.D. James P. Tasto, M.D. Jonathon Klassen


Introduction and Purpose: Arthroscopic subacromial decompression (ASD) has become an accepted treatment for impingement syndrome over the last 15 years. Advantages appear to outweigh traditional open procedures. There is little data in the literature addressing the acromioclavicular (AC) joint as a contributing factor in this syndrome. We have analyzed a retrospective series of 100 patients. We analyzed the incidence of AC involvement, the need for avoidance of co-planing, and overall general outcome for pain relief and return to normal activities. Materials and Methods: A retrospective study was performed on 93 patients with 100 shoulders undergoing ASD by a single surgeon using a consistent technique. An independent observer used a visual analog scale for follow up. No attempts at co-planing the AC joint were made during any of the operative procedures. Results: The average follow up time was 3.5 years. There were 5 distal clavicle resections (4 arthroscopic, 1 open). None of the patients developed AC joint symptoms following the procedure. Eighty-three percent had most of their pain relieved with overhead activity, and 90% felt they could tolerate all or most of their daily activities. Conclusion and Significance: Avoiding arthroscopic co-planing during a routine ASD resulted in no residual symptoms or revisions on the AC joint in this group of patients. A consistent and reproducible technique resulted in 83-90% good or excellent results. Resection of the anterior acromial prominence and avoidance of disruption of the AC joint are critical components of a successful ASD.

22. Inflammatory Cytokine Profiles Correlate With the Degree of Chondrosis in the Chronic Anterior Cruciate Ligament Deficient Knee.

Michelle Cameron, M.D. Paul Marks, M.D.


Introduction: The natural history of the ACL deficient knee has been, and continues to be, the topic of



much debate. Earlier studies have documented that patients with chronic ACL deficiency were at high risk for articular cartilage damage and eventual development of osteoarthritis (OA). The cause of cartilage loss in the ACL deficient knee is unknown. Our group hypothesizes that biochemical factors, such as cytokines, may contribute. The purposes of our study were to determine the concentrations of the chondrodestructive cytokines interleukin-l-15 (IL-1 [:t,) and tumor necrosis factor-o: (TNF-O:), and the chondroprotective cytokine interleukin-l-receptor antagonist (IL-1 ra) in the chronic ACL deficient knee; and to determine if the cytokine profile correlated with the amount of cartilage damage present. Methods: Synovial fluid lavages were obtained from 31 patients with chronic ACL deficiency (range 6- 144 months post-injury) at the time of ACL reconstruction. Prior to arthroscopy, 20 ml of sterile saline was injected into the knee, it was put through 10 full ranges of motion, and reaspirated. The lavages were centrifuged and the supernatant analyzed for IL-115, TNF-O:, and IL-1 ra, using commercially available ELISA kits. Additionally, samples were obtained from the contralateral normal knee in 4 patients. At the time of ACL reconstruction, the entire articular surface was visualized and the amount of chondrosis was graded 0-IV according to Outerbridge's classification system. The mean time from index injury for each grade of chondrosis was plotted and the line of best fit determined. A p value as determined by two-tailed t-test of _< 0.05, and an r 2 correlation coefficient of -> 0.95 were considered statistically significant.

Figure 1

IL-1E I~.1~ IL. ' I l l ~.IIF, l

Figure 3

~ ? M # I n ~ cLAur lu P ' ICA~JO~

~ l - l b

Click on Image to view full size

Results: Concentrations of chondrodestructive IL-1 15 and TNF-O:, and chondroprotective I L-lra were significantly higher (p_<0.05) in patients with ACL ruptures than in the contralateral normal knees (figure 1). Analysis of cytokine profile by Outerbridge grade demonstrated increased expression of chondrodestructive mediators with increasing severity of chondrosis, with a corresponding decrease in chondroprotective mediators (figure 2). Additionally, the severity of chondrosis increased as the time from index injury increased (figure 3). This correlated directly with an r 2 value of 0.954. Discussion: We are the first to shown a direct correlation between the time from index injury and the severity of cartilage damage in the knee; suggesting progressive cartilage loss over time. We have shown an overall increased expression of chondrodestructive and chondroprotective mediators in the

http://www2•us•e•sevierhea•th•c•m/inst/serve?n..•ti•n=sear•hDB&gr•up=J•hn+J•yce+Award+Fina•ists (5 of 6) [12/13/2007 11:59:21 AM]


synovial fluid of the ACL deficient knee when compared to normal knees. Suggesting a chronic derangement of cytokine expression in the ACL deficient knee. Furthermore, we have shown that as the level of chondrosis increases the amount of chondrodestructive IL-1 ~., and TNF-¢c increases, but the amount of chondroprotective I L-lra decreases. This imbalance between chondrodestructive and chondroprotective mediators in the knee may result in a progressive loss of cartilage in the ACL deficient knee eventually resulting in OA.


Documents

John Joyce Award Finalists