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					                                                                    IN         DEFENCE                                    OF            THE                      MENISCUS

                                             A PROSPECTIVE                                   STUDY                    OF          200           MENISCECTOMY                                                   PATIENTS

                                                                                                             J.     NOBLE,               K.      ERAT

                                                  From            The      Princess          Margaret                     Rose          Orthopaedic                        Hospital,                        Edinburgh

                   0f250      patients scheduled      for meniscectomy    50 had symptoms       which subsided    and operation   could be
            deferred;      ofthe remaining       200 only 73 per cent were found to have a significant         tear. It is shown that the
            risks of removing         a normal    meniscus     far exceed those of leaving a tear in the posterior       third. Statistical
            analysis     of clinical   features    revealed   no reliable diagnostic   pattern.

        The              advent        of arthrography                       and arthroscopy       have                                                                            MATERIAL                           AND             METHODS

highlighted                    the       difficulties               of        diagnosing     meniscal                                    Two         hundred              and       fifty          consecutive                    patients              scheduled               for     meniscec-

lesions.   Much     of the success    with these time-consuming                                                                          tomy         or,      in a few               cases,           for      exploratory                        arthrotomy                 for       a possible
                                                                                                                                         meniscal             tear,       were          studied              by one           observer.                  All    symptoms                    and      signs
techniques     appears      to have been in North     America.        At
                                                                                                                                         before          operation              were          recorded                on a detailed                      proforma,              as well            as the
the moment        it is likely   that only a minority      of British                                                                    radiographic                   features            and        all operative                      findings.            The       clinical            features
surgeons                 will acquire              that          expertise         with           arthroscopy                            were         then           correlated                with          the       meniscal                   and       intra-articular                       abnor-
described                 by Jackson               and          Dandy          (1976).            Indeed      it is                      malities.
probable,                  in the      current            economic              climate,               that         many                           The         diagnostic                groups               are          shown             in     Table           I. The             vertical            or
                                                                                                                                         oblique             tears        comprised                   30       per         cent       of the             findings          at       arthrotomy,
will      not      even         be able          to acquire              an arthroscope                       (Lancet
                                                                                                                                         while        horizontal                cleavage               lesions             were        encountered                      in 38.5             per      cent,
1976).                                                                                                                                   some         of which                 were           in     a less           well         recognised                  group            in      which             the
           Not           all    practitioners               of      arthrography                       (DeHaven                          bucket-handle                     tear         was         based            upon          a horizontal                 cleavage                lesion.            Of
and        Collins             1 975 ; Axer           et al.         1 976)        report          the            success                the      two        diagnostic                 groups               in which               the           meniscus           was         found              to     be

rate   of           over     90         per cent                 described           by those                       North
American               authors           who have                 become         particularly                      expert
                                                                                                                                         Table          I. Diagnosis
with        the      technique               (Nicholas,               Freiberger              and            Killoran
1970;           McBeath      and                 Wirka     1972;    Kaye                  and Freiberger
                                                                                                                                                                                    Diagnostic                  groups                                                                Per cent
1975).           The potential                    weakness       of both                 techniques      is in
demonstrating                       the posterior                third of the meniscus                           and it                       I . Vertical              or oblique                  tears

is here, where                    tears are most                 common,     that false                       positive                                   Bucket-handle                                                                                                              15.0
results        and false negatives   occur.
                                                                                                                                                         Complete                 peripheral                  separation                                                              7.5
           Although     the best compromise                                      may         be         to depend                                                                                                                                                                                  30.0
upon         a combination                       of clinical             diagnosis,           arthrography                                               Posterior              peripheral                   separation                                                               4.5

and arthroscopy,          the surgeon      first has to exercise             clinical                                                                    Posterior              horn          (fish-tail)                                                                             3.0
judgement        in selecting     patients      for either        investigation.
                                                                                                                                           2.      Horizontal                cleavage                 lesion
This    can only      be based       upon      clinical      features,        which,
despite     being       familiar,       have       previously           not      been                                                                    Posterior              third                                                                                               14.01

prospectively                    and     statistically              assessed            in terms                  of their                              Associated                  parrot-beak                                                                                     12.0      29.5
diagnostic     reliability.
       Despite      arthrography                            or arthroscopy                       the      situation
                                                                                                                                                        Complete                  meniscus                                                                                            3.5J
will       arise          wherein          the       knee          is opened               and          no         tear      is            3.      Horizontal               cleavage                lesion           and      bucket-handle                      tear                 9.0

obvious.             It is then that                 Watson-Jones’        (1956)   teaching                                                4.      Normal              meniscus-removed                                                                                             12.5
that the           cartilage    should               be removed       for fear of leaving      a
                                                                                                                                           5.      Normal              meniscus-left                          in place                                                              14.5
posterior             tear,  invisible               from     the front,   becomes      a real
threat    to the meniscus.      One has to balance    the risks of                                                                         6.      Cystic            lesion-alone                                                                                                     4.0
leaving     such   a tear against   those of excising    a normal                                                                          7.      Discoid             lesion-alone                                                                                                   0.5
meniscus.       No surgeon    can escape  this dilemma.

J. Noblc,  MB ChB      FRCSEd,       Senior     Lecturer                              in Orthopaedic                 Surgery,           University               of Manchester,                        Hope            Hospital,                   Eccles        Old       Road,              Salford
M6 8HD,     England.
K. Erat.  BA, Research     Associate       (Computer                             Science),             Department               of Surgery.              Peter          Bent        Brigham                  Hospital.               Boston,                Massachusetts                     02 I I 5,
Requests           for     reprints     should       be sent        to    Mr   J. Noble.

VOL.       62-B,         No.   I. FEBRUARY                980
                                                                                                                                                                        J.     NOBLE,                  K.    ERAT

normal                only            Group              4, in which                          the        meniscus                was       removed,                       was used                     Table      II. Intra-articular                         findings        in 54        knees       in which              the      meniscus
for          statistical                       comparisons                           as        “    normality”                      had          only                  then been                                           appeared                to be        normal
established                        beyond               doubt;                a comparison                            was          made,             however,                      for        all
clinical              features                   between                 these                two         groups.             The         eight              cystic            menisci                                                                                                                                          Number               of
and          the       one            discoid                meniscus                 which                did        not      have            an associated                               tear                                                             Findings                                                               knees
were            not        included                  in the           ensuing                 correlations.                    A further                    eight            meniscal
cysts           were             encountered,                         but      these                were          associated               with             meniscal                      tears         Chondromalacia                           patellae            or patellofemoral
                                                                                                                                                                                                        osteoarthritis                                                                                                                    15
and          were               classified              as such.
              The          symptoms,                     signs,          age          distribution,                        side,        sex,     type             of onset                  and         Synovitis            or synovial                    hypertrophy                                                                    9
duration                   of complaints                          were              correlated                      between                Groups                      1 , 2 and                  4.
For          simplicity                   only         the     more            important                        clinical           features                 are        considered                       Lesion            of the       fat       pad                                                                                           8
here.            Subsequently                            the          first      three               diagnostic                    groups             were     combined
                                                                                                                                                                                                        Ligamentous                   lesion                                                                                               4
into           one          “     tear          positive”                   group                  and        Groups                4 and               5 into    a “ tear
negative”                        group.              Computer                       programmes                            were          written                   in which                   the        Loose           body       or osteochondritis                        dissecans                                                     4
chi-square                       test      was         used           on any              combination                        of between                       two        and              1 0 of
                                                                                                                                                                                                        Tibiofemoral                  osteoarthritis                                                                                       3
the          following                    clinical             features:                  symptoms-pain                                   as the              predominant
complaint,                  pain    at                   night,     locking,     instability                                        and       effusion; signs-                                          Synovial            chondromatosis                                                                                                     1
wasting                or effusion,                      tenderness        or hyperaesthesia                                              over the joint line,                                     a
block            to extension                           and           a positive                    squatting                or duck-waddle                                   test.                     Ganglion                                                                                                                               1
               By          these               means            the           incidence                      of      these           features                     in     the          “    tear
                                                                                                                                                                                                        No      abnormality                                                                                                               15
positive”                       and        “    tear         negative”                        groups               could           be      compared.                           Further
comparisons                              were          made             for      each               patient,               by giving                 a point                 for          each
positive                   feature               and         comparing                         the         mean             points             score              between                    the
“     tear       negative”                       group           and           the        “    tear          positive”               group.                                                            horizontal                     tear,                 were           not          regarded                        as      significant
              Two               hundred                  and           fifty          patients                    were           originally                   called               in        for       abnormalities,    as they may be caused    by linear                                                                           traction
meniscectomy,                                  but      50 never                 underwent                          operation.                  The           reasons                     were
                                                                                                                                                                                                       upon     a curved    structure during   mobilisation                                                                              of the
as follows:                       25 spontaneously                                   improved                      while           awaiting                 operation                       and
asked               that          their         names            be removed                              from        the      waiting                list         and        a similar
                                                                                                                                                                                                       meniscus;                   neither                    were          menisci                 with          a frayed                     edge,
situation                   was discovered                             with          a further                  10 patients                on admission                               to the           discoloration,       softening      or fibrillation        “with   no frank
    hospital,               so that              they          were            dismissed                      without               operation                     ; another                       10   tear”      There
                                                                                                                                                                                                                    .       were      no significant        differences      in any
    patients               defaulted                   and       five          were                treated            conservatively.                                                                  respect      between    the arthrotomies         with negative      findings
               These              observations                        are only                 as statistically                     reliable                as the           clinician
                                                                                                                                                                                                       where       the meniscus        had been removed               and those     in
    who         originally                      made            them.                For            each            patient              the         clinical                 features
    recorded                 by         that         observer                 the         day            before            operation                  were              compared
                                                                                                                                                                                                       which            it had           been                left.
    with those                   recorded                the same day by the admitting                                                    surgeon.                      Where               any
    significant                   difference                   existed               between                      these       observations                             the      clinical
                                                                                                                                                                                                       Table       Ill.     Age        and sex of patients                           and side and onset                      of lesions
features                   were            reconsidered                         by both                    parties.
                                                                                                                                                                                                                            expressed                  as percentage                 distribution            in three              diagnostic
                                                        CLINICAL                                      FINDINGS
The majority   of patients      (63.2                                                                              per cent) had                                       an acute                                                                                         Vertical  or                  Horizontal                      Normal
                                                                                                                                                                                                                                                                       oblique tears                   cleavage                      menlscus
onset of symptoms,     associated                                                                                 with an injury,                                       whereas
    24.9           per            cent           had           an insidious                                  onset.                Between                         these                  two           Age       (years)

    extremes                          1 1 .9 per cent                               had an acute                                   onset              unassociated                                             10-19                                                          32.8                            7.0                         16.7
with                any            significant                          injury.                      Forty-three                               per           cent              of the
                                                                                                                                                                                                             20-29                                                            39.7                          24.6                         20.8
    patients    had had symptoms       for more than a year.
            Of the 200 patients    who underwent      operation,      146                                                                                                                                    30-39                           .                                   6.9                        12.3                         250

    had a significant       meniscal    tear,  giving    a diagnostic                                                                                                                                        40-49                                                            13.8                          26.3                         25.0
    accuracy                      rate           of 73 per                      cent;                 when                considered                              in relation
                                                                                                                                                                                                             50-59                                                               5.2                        17.6                           4.2
to the original    250 patients    scheduled     for operation,    this
represented     a diagnostic    accuracy     of only 58.4 per cent.                                                                                                                                          Over6O                                                              1.7                        12.3                               8.3

The features     identified   at arthrotomy,      in the 54 patients                                                                                                                                    Malepatients                                                          87.9                          86.0                         66.7
    in       whom                         the           menisci                           appeared                            to         be            normal,                              are
                                                                                                                                                                                                         Medial           meniscus                                            72.4                          77.2                         79.2
    enumerated        in Table II; in 15 of them no abnormality
    was identified.                                                                                                                                                                                      Onset
           There     were    3.2 meniscectomies       where  meniscal
                                                                                                                                                                                                               Less       than       1 month                                  10.3                            -                            -
    tears were found for every one with a normal             cartilage
    among      the male patients,      whereas   for the females      the                                                                                                                                      1 to       12 months                                           53.5                          50.9                         58.3

    ratio was 1 1 to 1 In 25 of the 54 patients
                                           .                where .    no                                                                                                                                      More        than        1 year                                 36.2                          49.1                         41.7
    abnormality       was found at arthrotomy      a normal meniscus
                                                                                                                                                                                                               Acute        and       traumatic                               81.0                          54.4                          58.3
    was removed,          usually in the spirit of Watson-Jones’
    teaching      and this represents       14.6 per cent of all the                                                                                                                                           Acute                                                          12.1                                7.0                     12.5

    meniscectomies                                       in this                      series.                     Transverse       tears                                      of the                           Insidious                                                         6.9                        38.6                          29.2
    anterior       horn                                 or mid                         portion,                       unassociated                                           with    a

                                                                                                                                                                                                                                                   THE        JOURNAL                OF BONE               AND          JOINT         SURGERY
                                                                                                                   IN     DEFENCE                OF   THE       MENISCUS                                                                                                                          9

            Whereas                   the        patients             with             vertical           or oblique                  tears           associations                          were             between                 a      block      to (or     loss   of)
were         younger                  and         had        shorter              histories               it is emphasised                            extension     and any combination                                                     of wasting,       tenderness
that         a third                 of       the          h#{224}rizontal               cleavage                  lesions            were            over    the joint line or ligamentous                                                    laxity.
encountered                    in people     under     the                                 age of 30 (Table                            III).                 With female    patients  there                                                 was an 80 per cent, or
The onset                   was acute    and traumatic                                      in 54.4 per cent                         of the           better,         chance                  of the arthrotomy          findings    being negative
patients               with          a horizontal                    cleavage                lesion,           and          insidious                 if the        pain was                  general   or ill-localised         and not associated
in 38.6     per cent.                            In contrast,      only   19 per cent of the                                                          with         effusion                 or a block                  to extension.                 Sixty-one                per      cent
group     with vertical                             or oblique      tears   had an onset     not                                                      of the male patients      with                                    negative             findings            at exploration
involving      trauma                             beyond      a trivial    domestic  incident                                                         had ill-localised    pain.
(Table              III).
            Pain         (including                    pain         at night)               was the predominant
complaint                   in less             than         half      of the             group            with          vertical           or        Table        V. Percentage                      incidence           of physical           signs         in three      diagnostic
oblique               tears    and was not invariable       at the onset     of the
history             in any of the three        groups  compared      (Table    IV).
                                                                                                                                                                                                                            Vertical  or                  Horizontal           Normal
Although                  pain    at night   was twice    as common         among
                                                                                                                                                                                                                           oblique tears                   cleavage            meniscus
patients              with horizontal      tears as in those     with vertical    or
oblique                tears,             it was             just          as      frequent                with            a normal                     Effusion                                                                    55.2                       50.9                  45.8

meniscus.                   Locking                  was         commonest                        with       the         vertical           or          Wasting              of the         quadriceps                              65.5                        59.7                 54.2
oblique                 tears             and          instability                 predominated                             with           the
                                                                                                                                                        Tenderness                   over    the
                                                                                                                                                        affected             joint      line                                        65.5                       79.0                  87.5

Table        IV.       Percentage                incidence            of symptoms                  in three             diagnostic                      Tenderness                 over         the
                       groups                                                                                                                           ipsilateral             ligament                                             15.5                      45.6                  33.3

                                                                                                                                                        Swelling             of the          joint      line                         17.2                      29.8                  41.7
                                                                      Vertical or                    Horizontal                   Normal
                                                                     oblique tears                       cleavage                meniscus               Ligamentous                    lesion                                       29.3                        14.0                 16.7

  Initial       complaint                 was       pain                        84.5                        19.2                   91.7                 Lacks         full      extension                                           46.5                       33.0                  33.3

 Pain        now                                                                44.8                        80.7                   75.0                 Lacks         full      flexion                                             37.9                       47.4                  41.7

 Pain        at affected              joint         line                        87.9                        89.5                   83.3                 Positive             McMurray                 sign                          62.1                       63.0                  41.7

 Night          pain                                                            46.6                        79.0                   79.2                 Positive             squat      or      duck
                                                                                                                                                        waddle                                                                      44.8                       61.4                  33.3
 Night          pain        which         disturbs
 sleep                                                                          29.3                        61.4                   62.5                 Hyperaesthesia                       over       the
                                                                                                                                                        joint   line                                                                20.7                       49.1                  25.0
 Night    pain              caused          by      knees
 touching                                                                       27.6                        59.7                    50.0

  Locking                                                                       84.5                        52.0                   45.8

  Instability                                                                   67.2                        71.9                   62.5                            In 20 patients                        (1 0 per cent)                     both        medial            and lateral
                                                                                                                                                       compartments                             were           opened,            although                in five of them                   the
  Effusion                                                                      69.0                        63.2                    70.8
                                                                                                                                                       second            arthrotomy                          was        delayed             for between                  one      and        six
 Stiffness                                                                      36.2                        54.4                    50.0               months.    In eight patients    both                                              menisci      were normal          and
  Symptoms                  on   walking                                        48.3                        79.0                    50.0               in four both were pathological,                                                   whereas       in the remaining
                                                                                                                                                       eight   the second   and previously                                                  unsuspected           compart-
                                                                                                                                                       ment    was the seat of a “silent,                                                 significant       tear”.

horizontal                 cleavage    lesion.     However,    52 per cent                                                           of the
patients               with horizontal        tears complained     oflocking                                                            and
62.5 per cent of those                                       with normal     menisci      complained                                                   Reliability                    of        clinical                features.             Despite                  a wealth               of
of      instability.       The                               incidence      of    tenderness         and                                               references                      to       the           signs        and           symptoms                     exhibited              by
limitations          of movement                                  are shown    in Table      V.                                                        patients               with          torn        menisci              this        is the       first      study         in which
            The average                          number              of clinical                  abnormalities                      in the            their        reliability   has been                               studied     prospectively.                          In 20 per
“tear     positive”                         group    was 13.3,     whereas        for                                       the “tear                  cent        of the patients    with                               a diagnosis      of torn                      meniscus    the
negative”         group                        it was 12.8.    This    difference                                             was not                  symptoms                      settled,           indicating                  their      unreliable                transience.
statistically                     significant,                    and            neither              were                the  other                   To date               we know                   that only             two of these                     50 patients               have
results       from               the other                  scoring             methods              applied.               The only                   subsequently                             come               to       arthrotomy,                        one         having                 a
symptom                     combinations                            with          a probability                         better         than            degenerate     tear, the other   having                                                      negative             findings              at
P<0.    1 were                         continuing                     pain,               effusion             and            locking;                 exploration.
locking    and                         instability;                    and               locking              and            effusion.                        As no specific sign or symptom                                                        consistently               means              a
Regarding                            signs,                the             only             significant                      (P<0.1)                   specific               lesion            it is best,                in all but               the        most        acute            and

VOL.        62-B,        No.     I. FEBRUARY                        1980
10                                                                                                                        J.     NOBLE,                K.     ERAT

obvious   cases, to examine         the patient                                                 two or three        times                             upon           traction                with      a blunt             hook              at arthrotomy.                       A small
over several    weeks      before     any firm                                                surgical     decision       is                          posterior   peripheral        tear which cannot                                                      be demonstrated
made.   The     similarity       of symptoms                                                      in those       with      a                          in this manner       is likely to be unimportant.                                                        The majority
horizontal               tear and      those     with     a normal   meniscus                                                                         of other                   posterior                tears         will            be      horizontal                   and        upon
siggests             a common     origin     which    could  be an underlying                                                                         applying               a little          traction              anteriorly                   and      viewing               from         the
synovitis.                More            important                than          any distinction    between                                           level         of the tibial                     plateau         it is usually      easy to see their
different                 types           of tear               is the          absence      of any reliable                                          ragged                border                  and         mouth.      As      cystic    and   discoid
clinical          pattern             differentiating                         between                the patients                     with            cartilages                   present            no diagnostic              problems,         concern
a torn             meniscus                      and those      without.                        The             decision      to                      remains                    only          regarding         posterior-third             vertical       or
excise            a meniscus                      should   therefore                         not be             based    upon                         oblique                tears,             the    so-called         fish-tail      lesions       which
clinical features.                                                                                                                                    represent                  only        three           per cent              of this         series.          Therefore,                  in
Clinical  significance                                  of meniscal                   pathology.                 That            54 of                this study,  the risks of leaving  such                                                   a tear in the posterior
the 200 patients                                 (27         per      cent)           who          underwent                      arth-               third   were   only   1 in 33, whereas                                                      those  of finding     no
rotomy             did not            have             a torn        meniscus                might           suggest             a lack               meniscal                   tear          and           therefore                   of       removing                   a     normal
of diagnostic                   acumen,    especially      as a number                                                  of series                     meniscus                   were          potentially                    one             in four.             Although                   the
make    little               or no mention      of finding     a normal                                                meniscus                       sequelae               of meniscus                       removal                  are well             known,              those          of
(Wynne-Parry,                             Nichols               and      Lewis             1958; Helfet    1959;                                      leaving               behind               a tear    in                 the            posterior               third         of         the
Appel             1970).            However,                       similar           sparse mention     is made                                       meniscus                remain              unknown.
of the        horizontal                         cleavage             lesion,          the      commonest                        of all                            Noble           and         Hamblen                 (1975)                 have        demonstrated                        the
meniscal      tears                  (Smillie   1970).                                                                                                possibility                 of severe               osteoarthritis                       coexisting               with       untorn
       Lipscomb                      and Henderson                             (1947)           found           that           in 21.7                menisci,                   and          vice          versa.            If        horizontal                  tears          of         the
per       cent           of the             series           at the           Mayo            Clinic           no      tear            was            posterior     third   are potentially          detrimental        to the
found             at operation;                            McBeath               and          Wirka             (1972)                 had            articular  cartilage,    then on the basis of their findings
similar           findings.                 More             recently            the     arthroscopic                          data       of          there must be at least three           million      people   in Britain
Dandy             and Jackson                        (1975)             and of DeHaven                          and Collins                           requiring    a meniscectomy.        Johnson        et al. ( 1 974)   and
(1 975)     have     shown       the diagnostic    difficulties     and the                                                                           Gear ( 1 967) have suggested          that the longer       the period
need for expert          arthroscopy.      It may be that the number                                                                                  between    the first complaint       and the operation           the less
of negative      findings      in our meniscectomy          series has been                                                                           favourable                       the      result;              however,                     Johnson’s                  follow-up
increased                  by       not          regarding               “discoloured                         menisci                 with            rate        was        22.5        per         cent      and       Gear’s                27 per           cent,        rendering
frayed            edges”             or      “    transverse                 tears      of the             anterior             horn”                 such conclusions                               suspect.            Both                Jackson             ( 1 968),          with            a
as significant.                                                                                                                                       larger              number              of patients                  and          a 90 per cent                      follow-up,
      The important                                 functions                of the      meniscus                   have          been                and Appel                     (1 970) have shown        that long-term      results                                                       of
demonstrated                          (Walker    and                    Erkman                1 975 ; Krause    et a!.                                meniscectomy                       are not adversely     affected    by the length                                                        of
1976),      and                    the long-term                        sequelae                of meniscectomy                                       time from                    diagnosis    to meniscectomy.
have         been            recognised                       for      some           time           (Fairbank                   1948;                             If,      at      arthrotomy,                       no           abnormality                      exists          in        the
Gear          1967;               Jackson                  1968;        Tapper               and         Hoover                 1969).                meniscus                   to which              the      clinical            features              pointed,               then         the
The        classical               teaching                  of Watson-Jones                          therefore                  needs                other       cartilage        should        be    examined.        Among             200
to be reviewed.                                  Whereas                we      would              not        question                  the           arthrotomies           there    were     1 2 cases where      either      the other
need   for early                      removal     of an acute,                                 displaced,               bucket-                       meniscus         or both were torn, although               unfortunately            this
handle     tear,                     the    risks   of leaving                                   other              significant                       was      not      always       recognised         at the     same        “sitting”.
meniscal                  abnormalities                         should           be     reconsidered.                                                 However,                     if one            is faced              with              an open              joint          and          two
      Undisplaced                        peripheral                          separations                can be readily                                apparently                    normal             menisci             then            nothing             is lost       by closing
demonstrated                          by increased                           mobility                of the meniscus                                  the joint                  and         awaiting             further               developments.

This study      was originally      stimulated       by Professors         J. I. P. James      and D. L. Hamblen       to wom        much                                                                   gratitude    is due, as it is to Mr John Chalmers
for his help in the preparation               of this paper.      Grateful       thanks     are due to all surgeons      and registrars                                                                      at the Princess     Margaret    Rose Orthopaedic
Hospital      who gave full access          to all their clinical      material      and much      friendly   help.  We are also most                                                                       grateful   to the Department       of Surgery     at the
Peter    Bent    Brigham       Hospital       in Boston,     Massachusetts,             for use of their    computer     facilities.

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Axer A, Segal D, Hendel D, et al. Arthrography                                                 and       arthroscopy              in the       diagnosis           of internal          derangement                  of the        knee.       Harefuah            1 976;91:61           -3    [in
Dandy Di,                Jackson          RW.          The     impact         of arthroscopy                 on the        management                  of disorders               of the       knee.         J Bone        Joint        Surg       [Br] 1975;57-B:346-8.
DeHavenKE,                   Collins HR. Diagnosis      of internal  derangement                                                  of the knee.               J Bone          Joint       Surg         [Am]        1975;57-A:802-10.
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VOL..     62-B,         No.    1. FEBRUARY                   1980

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