Arthroscopy - Science method

THANK YOU

Of course you can, currently the relationship between open surgery VS arthroscopic surgery in the repair of the rotator handle, I can estimate at 50/50%. The reasons are mainly due to economic factors. As director of a training program for Shoulder and Elbow surgeons, graduates must master both techniques. We do everything by both techniques: double or single row, TOE, parachute, upper capsule, SS cable reconstruction, etc.

Clinical evaluation of the knee joint remains the gold standard in deciding about the management in such scenario. Locked meniscus or bucket handle tears generally needs urgent treatment. As far as degenerative tears are concerned clinical examination commensurating with MRI findings can guide us about mode of treatment

An interesting methodology and analysis with some great results. Also demonstrating the fantastic influence of Freddie Fu in this field!

RASL procedure gives disappointing results

Posterior impingment

FHL tendinitis

OCL talus zone 7-8-9 of Rankin

Ankle arthrodesis

Subtalar arthrodesis

Os trigono disseases

Haglund´s syndrome

Achilles tendinophaty insertional and corporal

FHL transfer

Non-surgical management is an option that is available via physical therapy. Proper exercise prescription could assist in increasing functional status and thus, minimize arthritic symptoms experienced by those with chronic meniscus damage and progressing degeneration. The following link demonstrates that altered gait mechanics may be a result of arthroscopy thus adding to the potential risk of osteoarthritis. The introduction in this article also provides other sources that discuss the risk of arthroscopy and advanced arthritis. 

punt

Hi

Usually MRI images are considered for meniscus implant sizing for better precision. These articles may help you,

Thanks and regards,

Mamatha

Risk stratified approach ensures patient safety. An interesting comparative study of 3 common agaents is: Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty.

Available at http://www.ncbi.nlm.nih.gov/pubmed/24695091

What would  be really interesting is to find studies with surgery site and systemic complications following aggressive thromboprophlylaxis as an end point rather than diagnosis of DVT!!! Surprisingly, the number is extremely limited. 

If the results are mixed, then the indications should be made clear. I never use viscosupplemenation injectoins in advanced OA (i.e.grade 4 ) because in the majority of these patients it fails, and the patients are disappointed.

Hey Mike :) What you describe is exactly what I did earlier - however I believe I went with 3 separate flushes rather than just one - typically helps to get everything out when you flush more than once (a bit like a BAL). I also remember using joints which were cut out right before and after the ankle so I had access to the joint quite easily and the liquid that came out was pretty clear. It was a bit messy but I got plenty of inflammatory cells and not much blood. The results we got then were pretty consistent. I'll send you the PDF by email. 

Anaesthetic nerve block is more commonly associated with Sensory neuropathy ( most common complication). It is regularly done for shoulder arthroscopy for post operative pain control

Thank you Lauren for this very good answer. I do agree with most of these relevant points even if I'm now much more aggressive with this recurrent pathology... Some authors confirmed that point and on my own experience results of arthroscopic debridements are really good... Nice day!

This is a really good question that perfectly highlights the place of hip arthroscopy in diagnosis and treatment of hip diseases!!!

I do agree with all the answers already given and surgeries mentioned, but regarding HIP AVN - and as previously said - we're talking about a vascular bone disorder for which all the evidence-based treatments do not require any invasive or non-invasive  primary joint approach. As previously said, and except some side-related pathologies such as labrum defects, inflammatory lesions, loosed bodies, ..., for which arthroscopy might be primarily indicated, the most efficient treatments usually require (if necessary and possible) a bony trans-cervical approach for drilling and grafting, and not a joint approach or intra-articular vision. So, I'm not sure that pre-collapse non-arthritic AVN core decompressions might really be improved by arthroscopic-assisted techniques and that the assessment of articular cartilage and underlying subchondral bone status is useful enough to modify either diagnosis or therapeutic protocol. For diagnosis as well, I would not recommend to use such techniques that are not specific enough regarding MR Imaging...

The problem remains the same with complementary treatments such as Autologous Conditioned Serum (ACS) injections that do not require any intra-articular vision.

And we should remind some rare cases of AVN described after simple arthroscopy  that were related to vascular traction during joint expansion...

See: Hip Int. 2011 Sep-Oct;21(5):623-6. doi: 10.5301/HIP.2011.8693.

Avascular necrosis of the femoral head after hip arthroscopy.

Sener N1, Gogus A, Akman S, Hamzaoglu A.

I do have considerable experience with trochleaplasty but feel that it is not indicated in grade 1dysplasia.  I therefore agree with a combined TT Transfer with MPFL Reconstruction in this patient. 

I think arthroscopy in fracture domain should be an adjuvant means. In some cases it is selective surgery.

Dear Ravi

The treatment of a meniscal injury will depend on its location, size, time of occurrence, age and level of sports activity of the patient. In my opinion, the treatment may be non-surgical for elderly patients with low functional demands and the remaining patients i performl arthroscopic surgery, even with minimal damage because I agree with you that this minimal lesion can evolve and cause more damage than it was

It's OK, Jonathan.

Of course the drug therapies today are more efficient than those some 40 years ago in "almost all cases". Anyway, what about the rest of primary cases that do not respond positively.

Furthermore, I am sorry to state but I don't think the removed synovium is replaced by only fibrous scar tissue. In 2 months after subtotal synovectomy (which is the typical procedure) the synovium regenerates quite well. The only difference is that the regenerated synovial membrane is richer on fibrous elements and poorer on blood vessels. This fact is favorable as far as a renewed inflammation is expected. Of course during this period of regeneration an appropriate exercises program is administered to avoid restricted range of joint motion.

Dear Ravi

Below comments from Bernard R. Bach, MD, - What Do You Do If You Drop the Graft on the Floor? Healio Orthopedics.

Great care must be taken to avoid contamination during harvest and or preparation of the graft for anterior cruciate ligament (ACL) reconstruction. Our protocol emphasizes that the surgeon who harvests the graft personally walks the tissue to the back table to reduce the risk of dropping the graft. Handing off of a freshly harvested graft to other members of the surgical team for preparation simply increases the likelihood dropping the graft. With this protocol, the senior author has not dropped any grafts in over 20 years of practice, including more than 1700 knee ligament procedures. Careful attention must be paid during preparation on the back table as well. The fully prepared graft is placed in a marked kidney basin. All operative personnel are informed to prevent the graft from being inadvertently passed off the sterile field

When the graft is brought to the operative field for graft placement, if it is wrapped in a laparotomy sponge, theoretically the only contaminated portion would be the sutures extending beyond the sponge if the graft were dropped.

If the graft is dropped, the salvage falls into one of several possible categories, namely cleaning the graft, using an alternative graft (auto or allograft), or stopping the procedure and completing the surgery at another time with a different graft.

One study showed a 58% rate of positive culture when the graft was dropped and left on the operating room floor for 15 s. Molina et al have shown that a 90-s soak in chlorhexadine gluconate is the most effective method to resterilize the graft

Another report found that a 30-min soak in 4% chlorhexadine followed by a 30-min soak in triple antibiotic solution (gentamicin, clindamycin, polymixin), followed by sterile saline wash was 100% effective in sterilizing contaminated rabbit patellar tendon grafts. In that same study, 10% povidone-iodine was 100% ineffective, as was triple antibiotic soak used in isolation.

A survey of sports medicine specialists found that most would choose cleansing the graft to manage the problem of a dropped graft. Forty-three surveyed surgeons reported having cleansed a contaminated graft and none reported postoperative infections.3

Another option is choosing an alternative graft. This requires preoperative consent from the patient or intraoperative consent from a family member and may be problematic for a patient who expects one graft type but ends up with another. Some surgeons routinely consent their patients for the use of an allograft should the autograph become contaminated or otherwise compromised. Again, if this option is selected, preoperative discussion with the patient is best because cultural or religious beliefs may preclude the use of cadaveric tissue.

Our preference would be cleansing the graft using a 30-min soak in 4% chlorhexadine gluconate followed by lavage with sterile saline, then another 30-min soak in triple antibiotic solution (0.1% gentamicin, 0.1% clindamicin, 0.05% polymyxin) and another sterile saline wash. Washing the chlorhexadine is crucial because chlorhexadine-induced chondrolysis has been reported.4 While this protocol is time consuming, it has solid scientific backing and would allow one to proceed with the same graft as planned preoperatively. One could consider a course of postoperative antibiotics, although we would refrain from this as it would likely only mask an underlying infection, delaying its definitive treatment. In addition, we recommend full disclosure to the patient regarding the incident and the low likelihood of any residual difficulties.

References

1. Molina ME, Nonweiller DE, Evans JA, DeLee JC. Contaminated anterior cruciate ligament grafts: the efficacy of 3 sterilization agents. Arthroscopy. 2000;16:373-378.

2. Goebel ME, Drez D Jr, Heck SB, Stoma MK. Contaminated rabbit patellar tendon grafts: in vivo analysis of disinfecting methods. Am J Sports Med. 1994;22:387-391.

3. Izquierdo R Jr, Cadet ER, Bauer R, Stanwood W, Levine WN, Ahmad CS. A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts. Arthroscopy. 2005;21:1348-1353.

4. Van Huyssteen AL, Bracey DJ. Chlorhexadine and chondrolysis in the knee. J Bone Joint Surg Br. 1999;81-B:995-996.

In my humble opinion we should distinguish what we consider basic arthroscopic surgery and arthroscopic surgery with high specialization , for many years as head of a Department of Orthopaedic Surgery and Traumatology of a University Hospital , with specialized sections in different pathologies , my opinion is that during training as a specialist, the medical trainee should know the basic techniques of arthroscopic of knee surgery ( meniscectomy , biopsy, synovectomy ) and to know shoulder entrance gates and have the knowledge to make an acromioplasty . After the period of specialization a time of special training and a long learning curve is absolutely necessary to perform more complex techniques in knee and shoulder , or be able to perform arthroscopic surgery of ankle , hip or wrist

I believe that to perform these techniques with a high degree of efficacy and safety , it is necessary take into acount , the category of the hospital, its technical possibilities and the demand for care prior to making the decision to initiate these

With all respect to the authors of the study and the editorial board of the journal, we should be very cautious in interpreting the results of a single study that supports an idea or concept that is in contrast to the current clinical practice and our common sense. As we all know, there is despite the possibility of scientific fraud (which I would exclude in this case, but look at historic fake studies etc.) there is a lot of room for bias and error.

First of all, we do not know, how exactly the partial meniscectomy was performed (radical, little resection…, although described by the authors. Several surgeons might have different understandings of the same terms…). I do share the critizism, that there is no information about mechanical axis, joint load etc., patella problems… which probably would have been asked for in an orthopaedic journal…!

The number of patients n=146 is very small, especially for a multicentre study!

The fact, that the authors cannot find a difference between both groups, does not mean, that there isn’t one (type-II-error). This is a frequent misinterpretation in orthopaedic manuscripts.

I have calculated the power of the study results based on the means, standard deviations and sample size provided in Table 1 of the paper with the following results:

Power one-sided power two-sided

Lysholm knee score 0.05 0.05

WOMET score 0.33 0.28

Score for knee pain after exercise 0.22 0.15

Score for knee pain at rest 0.19 0.12

15D score 0.26 0.17

(G*Power Version 3.0.10, Franz Faul, University of Kiel, Germany. Post-hoc analysis, t-test, n1=n2, α-error 0.05)

A power of 0.8 or more usually is considered to be good. This was intended by the authors in an a priori power-analysis. They fail by far to meet an acceptable power of their analysis.

If I take the results for the scores with their SD and calculate an a priori sample estimation, the necessary number of patients in the study would have been: 336914, 381, 699, 965 and 567 in the same order of scores as above!

It is interesting, that the authors do not comment on this, although apparently statistical consultancy was given.

There are some other issues: the patients in both groups were overweight (mean).

A left meniscus lesion does something harmful with the knee: it causes swelling, does mechanically damage the cartilage, activate inflammation cascades and enzymes and cytokines… This is very difficult to measure and is not considered in the sham group. What do the authors think, happended to the torn meniscus?

After successful partial medial meniscectomy I would expect the patient to be in the following condition after one year postoperative: no limping, full weight-bearing, no giving way or locking, no pain, no swelling, no problem climbing stairs, no problem to perform squatting. This “perfect” patient would result in a Lysholm score of 100 points. Noticable pain during heavy exertion, swelling during heavy exertion, little problems climbing stairs and limitation of sqatting not more than 90 degrees would be a less favourable but acceptable result. This patient would still have a Lysholm score of 84 points! Both groups only reach 60 point one year after surgery / sham surgery! Why is that? There are probably other reasons than only the meniscus…

My greatest concern is the last sentence in the conclusion: “These results argue against the current practice of performing arthroscopic partial meniscectomy in patients with a degenerative meniscal tear.” This is not true. As explained above, the authors did not prove, that there is no difference between both groups but instead they were not able to show a difference. To transfer this into the clinical setting, the sentence would be: “These results argue against an attempt to stop performing arthroscopic partial meniscectomy in patients with a degenerative meniscal tear (because the uselessness or inability to show a benefit after one year of intervention could not be shown).” This is a complete different story.

The Editors of the NEJM should be aware of this. I don’t know, why they did not intervene…

This study probably started with good intentions. Now it probably will cause a lot of discussion and misinterpretation of the findings and in my personal opinion, will not help to treat our patients better.

My personal conclusion: although we all can be wrong with “gut feelings”, you can never beat common sense with statistics.

Dear Michael,

even though, it has been more than one year, since you came up with this question, I remembered it when I found this publication on this topic. Maybe it helps you.

Osteoarthritis Cartilage. 2013 Jun;21(6):806-14. doi: 10.1016/j.joca.2013.03.007. Epub 2013 Mar 18.

A rapid, novel method of volumetric assessment of MRI-detected subchondral bone marrow lesions in knee osteoarthritis.

Ratzlaff C, Guermazi A, Collins J, Katz JN, Losina E, Vanwyngaarden C, Russell R, Iranpour T, Duryea J.

Dear Gustavo

Criteria are:

1. Age of patient

2. Time of injury (Acute or Chronic)

3. Area of injury

4. How extended is the injury

5. Complexity of injury

6. Activity of patient

So young active patient with acute extended unstable tear of meniscal injury situated in the red zone mainly and without ligament injuries (or injuries that are planned to be repaired or reconstructed during surgery), would be better to have this fixed.

Dear Shaw-Ruey Lyu, cartilage repair may occur spontaneously, but it depends on a lot of parameters as cause for cartilage lesion, size, depth, configuration, general health of the joint, systemic conditions, biomechanics etc. E.g. in case of osteochondral lesions the subchondral bone layer is opened and progenitor cells may invade the forming fibrin clot and finally differentiate into cartilage like tissue. This is a similar mechanism as it is supposed to occur after microfracturing. Stem cells may also invade from the synovia, but again success varys with the different influencing factors. Best regards, Hagen Schmal.