Questions related to Arthroscopy
If an MRI knee scan identifies a meniscal tear; what factors are taken into consideration to send for arthroscopy? If the scan has been generated from a GP referral: is there vetting to decide urgent or routine orthopaedic appointment from the results and onward freferral? Does it matter what type of tear? Do certain tears warrant more immediate intervention? If the scan also shows OA / degeneration, how much does that affect the decision to go ahead with a scope?
While the patellar tendon was more popular in the early 1990s, the hamstring tendon appeared more frequently starting in the late 1990s and steadily increased. The patellar tendon plateaued in the 1990s. Double-bundle reconstruction had an interesting timeline, with a rapid increase in publications from 2005 to a peak in 2011; that trend has been decreasing. The anterolateral ligament started appearing in 2013 and is showing an increasing trend. Allografts have seen a slow and steady increase,starting in 1985, it witnessed a dip from 1997 to 2001. The trend from then has been steadily increasing. (https://doi.org/10.1177%2F2325967119856883).
Arthroscopy has widened immensely its use in knee surgery. In my opinion its application today outweighs the need for it in degenerative disease of the knee.. What is your opinion and experience ?
Would like any literature or experience on patients that continue to have pain several months after an ankle arthroscopy. These patients have had an aggressive debridement with or without an OCD and reimaging results in negative pathology. They are not showing success with physical therapy. CRPS has been ruled out as well. Is there success with revision arthroscopy? Does knee arthroscopy literature offer any similar results or recommendations? Even though the joint mechanics and kinematics are different it would be helpful to know.
I'm mostly interested in whether X-ray or MRI was used, whether operated or contralateral knee was measured and which parameters were considered.
Some arthroplasty surgeons advocate for an individualized DVT prophylaxis regimen following hip and knee arthroplasty, one that balances safety and efficacy, based on an individual patient risk factors for developing a DVT. However, there seems to be a lack of high-quality data to guide surgeons when making this determination.
These are the only studies I could find:
1) Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am. 2007 Dec;89(12):2648-57. PubMed PMID: 18056497.
2) Nam D, Nunley RM, Johnson SR, Keeney JA, Clohisy JC, Barrack RL. Thromboembolism Prophylaxis in Hip Arthroplasty: Routine and High Risk Patients. J Arthroplasty. 2015 Dec;30(12):2299-303. Epub 2015 Jul 2. PubMed PMID: 26182980.
3) Nam D, Nunley RM, Johnson SR, Keeney JA, Clohisy JC, Barrack RL. The Effectiveness of a Risk Stratification Protocol for Thromboembolism Prophylaxis After Hip and Knee Arthroplasty. J Arthroplasty. 2016 Jun;31(6):1299-306. Epub 2015 Dec 17. PubMed PMID: 26777547
4) González Della Valle A, Serota A, Go G, Sorriaux G, Sculco TP, Sharrock NE, Salvati EA. Venous thromboembolism is rare with a multimodal prophylaxis protocol after total hip arthroplasty. Clin Orthop Relat Res. 2006 Mar;444:146-53. PubMed PMID: 16446593.
5) Bohl DD, Maltenfort MG, Huang R, Parvizi J, Lieberman JR, Della Valle CJ. Development and Validation of a Risk Stratification System for Pulmonary Embolism After Elective Primary Total Joint Arthroplasty. J Arthroplasty. 2016 Mar 17. PubMed PMID: 27067463.
Recently AAOS recommended against any benefit provided by viscosupplementation. The insurance companies stopped supporting this treatment. After this, there was an editorial in the journal "Arthroscopy" against the recommendations of AAOS. To this editorial, the AAOS authors gave a rebuttal.
I have personally used this treatment in many patients. The results are mixed. But still there are quite a good number of patients who feel significant improvment in their symptoms.
I'm trying to do flow cytometric analysis of the inflammatory cell infiltrate in the arthritic joints in mice. I've been targeting the ankle and "wrist" joints. I've tried to wing it (flushing with 1 mL PBS/2 mM EDTA/10% FBS using a 25G needle) but the variability from mouse to mouse is very high. I haven't found an article that describes the precise methodology for flushing the joints for flow or cytokine analysis. Does anyone have a protocol they trust?
It looks like that this pathology seems misdiagnosed and mistreated in some countries all other the world. Nevertheless, the responsibility of this structure seems well established and, as far as I know, there is no doubt about it's responsibility for severe anterior knee pain, osteomalacy, osteochondritis or severe impingement.
What is your feeling about it and which therapeutic options are yours for these specific pathological situations: fast and easy arthroscopy or conservative treatment?
Hip arthroscopy is getting more and more popular, especially for femoroacetabular impingement syndrome. Is there a rationale to apply it in cases with femoral head osteonecrosis, for example for early diagnostics and treatment ?
Interested in learning best ways to immobilise human subject's lower limbs with out causing much inconvenience to the subjects.
I usually perform distalization of tibial tubercle as the first procedure to correct the patella alta. If need be, I add MPFL reconstruction as the second staged procedure. I never had to add trochlear plasty.
Removal of haematoma is supposed to be chondroprotective, but does this justify the additional application of arthroscopy during or before open reduction and internal fixation? How about visual control of intraarticular steps? Is it possible to find additional pathologies as cartilage flakes and treat this? Is arthroscopy in fracture treatment limited to special joints?
Some experts say that up to 7 mm full thickness of longitudnal tears, and any length of partial thickness for longitudnal tears reaching to only one surface (femoral or tibial) can be left untouched.
I have always been wary about leaving them behind because I feel they are the trigger points for future extensions.
I like this old study by Hubbard from the JBJS. It is a well designed study with a clearly defined patient cohort and they showed a clear benefit to debriding focal osteoarthritic lesions of the medial femoral condyle.
Since this study there have been three sham surgical trials on knee arthroscopy, each greeted with a media fanfare, the problem for me is that despite these studies being interesting to a degree, I am not convinced that knee arthroscopy is as dead in the water as some physicians seem to want it to be. Why?
Well, there are some serious flaws in all these studies in terms of patient groups (heterogeneity/symptoms/stage of OA/type of OA lesions etc), outcome measures and study power. For example in the trials of Moseley and Kirkley they took heterogeneous groups of patients with diffuse OA of different stages and showed that a general bit of non-specific debridement (ie no chondroplasty/microfracture etc) did not improve outcome. While in the recent study by Sihvonen patients had no mechanical symptoms, and isolated knee pain with no arthritic lesions.
From what I can see we have learnt some interesting things from these sham surgical trials, for example we know that a general bit of non-specific debridement is probably not a good thing for people with knee pain related to diffuse osteoarthritis and no mechanical symptoms, and we have also learnt that a meniscectomy is not a good thing in terms of relieving pain in patients with an isolated degenerate meniscus, no osteoarthritis and no mechanical symptoms.
It will be interesting in the years ahead to see the role of knee arthroscopy become better defined, in my opinion the baby should not be thrown out with the bath water at this stage. We know focal osteoarthritis lesions respond better with surgery, and the role of modern treatments like chondroplasty/MACI/ACI needs to be better determined. The problem is I don't think that knee arthoscopy is of no value in the treatment of knee pain as a result of more diffuse osteoarthritis, I just think the evidence is not good enough to tell us the answer yet, it all depends on what one does once inside the knee and in which specific patient groups one intervenes.........
I see that the arthroscopic synovectomy gains in popularity nowadays. However, the idea of synovectomy in RA is to remove possibly the whole synovial membrane (total or subtotal synovectomy) so that the inflammatory process loses its ground. I wonder if this is possibly by means of arthroscopy ?
During the anterior cruciate ligament reconstruction, my hanstring graft (STG) has fell on the floor accidently twice. I did not have option of the allograft. I only had the options of either harvesting the same side BTB or contralateral hamstring or using the same graft after cleansing it. I exercised the last option of washing the graft with 500 ml saline, soaking it in cidex for 30 minutes and again washing it with saline. I was fortunate enough that in both the patients there was no infection. Both the patients have completed 2 years and 5 years follow up and the KT assessment as well as functional assessment is good.
But is it the right way to go in this situation or we should always harvest another new graft?
The arthroscopic surgery of each joint is emerging as a separate sub specialty with an increase in the number of pathological conditions and the emerging technical procedures.
At the same time the arthroscopy is an art which requires a fine balance of hand eye coordination.
Especially in the developing countries, the number of orthopaedic surgeons expert in the art of arthroscopy are a few. So should the practice of arthroscopy by individual surgeons be region wise restrictive or a surgeon who has mastered the art of "hand eye coordination" be promoted to practice arthroscopy on all the joints.
Recently, a new randomized controlled clinical trial comparing partial menistectomy and sham surgery in patients without relevant osteoarthritis of the affected knee has been published (Sihvonen et al., NEJM 2013: http://www.nejm.org/doi/full/10.1056/NEJMoa1305189).
In summary, clinical outcome at 12 months in the "partial menistectomy" group was no better when compared to sham surgery, while significant improvement from baseline was found in both groups.
What is your interpretation of the results of this study ? What conclusion can be drawn by this study ? Do you think the study has significant limitations ? What do you consider the reason for improvement in the sham arm of the surgery ?
Since King, 1936 classic research:“For meniscal lesions to heal they must communicate with the peripheral vasculature of the meniscus.” a lot of things have been said. Nowadays, proper patient selection plays a key role in successful outcomes. What do you think?
Presentation Meniscal Injury
Does anybody have the experience of observing cartilage regeneration by itself directly or indirectly (for example, by radiography)?