Open and arthroscopic approaches for meniscus surgery

Category: Midfoot/Forefoot; Arthroscopy Introduction/Purpose: Newer arthroscopic and minimally invasive (MIS) surgical techniques and instrumentation have made it increasingly easier to perform small-joint diagnostic arthroscopy and procedures that have been generally performed in an open fashion. These newer techniques have now been used for long enough that sufficient patient populations with long-term follow-data data are becoming available for comparison to traditional open cheilectomy. Our study sought to determine whether there is a difference in patient-reported outcomes (PRO) between MIS and open hallux cheilectomy as the number of patients undergoing the MIS version of the procedure increases and more long-term follow-up data becomes available. Our hypothesis was that patient-reported outcomes would be better for MIS cheilectomy at short-term follow-up but would even out over time with longer term follow-up. Methods: A retrospective chart review of all hallux MTP cheilectomies (CPT 28289) between 2015 and 2023 was performed within a single academic healthcare system. Chart review was then undertaken to collect basic demographics and determine if the patients had an open or minimally invasive cheilectomy. PROs were collected in a prospective fashion as part of the institution’s PRO registry starting in 2018. Patients with a completed measure of PROMIS Physical Function (PF), Pain Interference (PI) and/or Foot and Ankle Single Assessment Numeric Evaluation (FA SANE) at baseline, 3-, 6-, 12-, and/or 24-month postoperative timepoints were included in analysis. Differences in average PROs at each timepoint, both within and between cheilectomy type, were determined non-parametrically using Wilcoxon Rank Sum Tests. The average improvement of patients with a preoperative and at least one postoperative measure for each group were compared using an unpaired t-test. A p-value of < 0.05 was considered statistically significant. Results: In total, 172 patients with completed PROs were included in analysis. Average age was 53.2±11.4 and 111 (65%) of patients were female. The open approach was performed in 118 (69%) patients and 54 (31%) patients had a minimally invasive approach, consisting of hallux MTP arthroscopy followed by bone resection with an MIS burr under fluoroscopic guidance. For all PROs, the open and arthroscopic approaches demonstrated similar averages at each time point, and improvements in both techniques reached statistical significance (figure 1). There was no statistically significant difference in overall improvement by procedure type for PF (p=0.257), PI (p=0.544), or FA SANE (p=0.723). These corresponding improvements for the open approach were 5.18±8.67, -5.99±8.33 and 17.83±30.5 while the arthroscopic approach improvements were 3.33±7.69, -5.03±7.33, and 15.66±28.34 respectively. Conclusion: Arthroscopic and open approaches to hallux MTP cheilectomies have similar postoperative PRO improvements, and both techniques ultimately result in significant improvement. The magnitude of these improvements are not different based on technique at longest follow up. Thus, arthroscopic approaches are non-inferior to the traditional open approach. Further work is needed to determine if additional surgeries performed in parallel with cheilectomies may be affecting the observed PROs. Additionally, current work is being done to assess how functional, clinical, and radiographic outcomes align with PROs following MIS or open cheilectomy.

Arthroscopic distal clavicle excision is associated with fewer postoperative complications than open.

Purpose:Calcaneonavicular coalition accounts for more than half of all tarsal coalitions. Resection of calcaneonavicular coalition by an open approach is the standard treatment. Treatment of calcaneonavicular coalition by an arthroscopic approach appears promising. The objective of our study was to compare the clinical outcomes of calcaneonavicular coalition resection by open approach versus arthroscopic approach.Methods:A retrospective cohort study was conducted to evaluate 127 patients who underwent a resection of calcaneonavicular coalition from 2009 to 2017. Patients were divided into two groups according to whether an arthroscopic approach or an open approach was used. Demographics, operative parameters, and clinical outcomes (foot and ankle ability measure score, subjective score, and global ankle estimation) were assessed.Results:Arthroscopic approach was used for 81 patients and open approach for 46 patients. Treatment with arthroscopic approach resulted in a shorter hospital stay (2.6 ± 0.6 days vs 3.0 ± 0.7; p = 0.02) and a longer operative time (24.5 ± 8.1 min vs 20.5 ± 4.2; p < 0.01) than with open approach. The foot and ankle ability measure sports subscale scored significantly higher in the arthroscopic approach group (90.9 vs 77.3; p = 0.003). Revision rate was significantly higher in the arthroscopic approach group (12 (15%)) versus the open approach group (1 (2%)) (p = 0.024). Persistent symptoms (n = 12) were the main reason for revision.Conclusions:Arthroscopic treatment of calcaneonavicular coalition is associated with a higher revision rate than the open approach.Level of evidence:Level III—retrospective comparative study.

Arthroscopic and open approaches for autologous matrix-induced chondrogenesis repair of the knee have similar results: a meta-analysis

Background: In cases of recurrent anterior shoulder instability with a glenoid defect, Latarjet procedures are widely used for stabilization. Although complications with this procedure have been reported, few studies have comprehensively analyzed issues related to the Latarjet procedure. Purpose: To identify the overall complication rate of the Latarjet procedure used for anterior shoulder instability and to compare the rate of complications between arthroscopic and open approaches. Study Design: Systematic review; Level of evidence, 4. Methods: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed by using the PubMed, EMBASE, Scopus, and Cochrane Library databases. Data on complications were extracted and classified as intraoperative, postoperative, or instability-related for further analysis. Quality assessments were performed with criteria from the Methodological Index for Nonrandomized Studies (MINORS). A quantitative synthesis of data was conducted to compare the complication rates between arthroscopic and open approaches. Results: A total of 35 articles were included in this analysis. The MINORS score was 11.89. A total 2560 Latarjet procedures (2532 patients) were included. The overall complication rate was 16.1% (n = 412). The intraoperative complication rate was 3.4% (n = 87) and included a 1.9% (n = 48) incidence of nerve injuries and a 1.0% (n = 25) incidence of iatrogenic fractures. Screw problems, vascular injuries, and conversion arthroscopic to open surgery each occurred at a rate of <1%. The postoperative complication rate was 6.5% (n = 166), and the most common complication was nonunion (1.3%; n = 33). The instability-related complication rate was 6.2% (n = 159) and included a 1.5% (n = 38) rate of redislocation, a 2.9% (n = 75) rate of positive apprehension test, and a 1.0% (n = 26) rate of instability. Overall, 2.6% (n = 66) of patients required an unplanned secondary operation after the initial surgery. The arthroscopic approach was associated with a higher rate of intraoperative complications compared with the open approach (5.0% vs 2.9%; P =.020) and a lower rate of instability-related complications (3.1% vs 7.2%; P < .001). Conclusion: The Latarjet procedure for anterior shoulder instability results in an overall complication rate of 16.1% and a reoperation rate of 2.6%. However, serious complications at short-term follow-up appear rare. When the arthroscopic approach was used, the rate of intraoperative complications was higher, although instability-related complications were lower when compared with the open approach.

Objectives:Overhead athletes place extraordinary physiologic demands on the shoulder during athletic activity. Repetitive microtrauma can result in attenuation of important capsuloligamentous structures that are responsible for providing glenohumeral stability resulting in symptomatic instability. Surgical management can utilize either an arthroscopic or open approach to shoulder stabilization; however, there is a paucity of data to support a specific technique and guide surgical decision making in this unique patient population. The purpose of the present study was to determine functional outcomes, including return to play, range of motion (ROM), validated outcome scores and recurrent instability following arthroscopic and open shoulder stabilization in overhead athletes diagnosed with anterior instability.Methods:MEDLINE and the Cochrane Database of Systematic Reviews were searched. Eleven articles matched our selection criteria for randomized controlled trials in which a cohort of overhead athletes participating in sports including baseball, tennis, volleyball, and freestyle swimming, were surgically treated by capsular plication or Bankart repair through either an open or arthroscopic approach for anterior shoulder subluxation or dislocation. The studies were assessed for methodological quality and relevant data was extracted and further evaluated. Results of comparable groups of trials were pooled and mean differences as well as 95% confidence intervals were calculated for continuous outcomes. A grading schema was designed to assess return to play: return to the same level of play (Grade 1), diminished level of play (Grade 2), and failure to return to play (Grade 3).Results:In overhead athletes with anterior glenohumeral subluxation or dislocation, return to play was similar between arthroscopic and open approaches (Grade 1 = arthroscopic 72 ± 22.6%, open 68.7 ± 7.8%; Grade 2 = arthroscopic 24.2 ± 18.3%, open 34.5 ± 7.8%; Grade 3 = arthroscopic 7.2 ± 10.8%, open 8.3 ± 14.4%). Arthroscopic and open approaches demonstrated similar changes in post-operative ROM, as evaluated through degrees of external rotation (arthroscopic -3.6 ± 1.9o, open -3.9 ± 1.9o), forward flexion (arthroscopic -2 ± 1.4o in FF, open -2.7 ± 3.82o), abduction (arthroscopic -0.7o, open -4.6o) and internal rotation (arthroscopic -2.7o, open -2.5o). No significant difference in functional score outcomes existed between arthroscopic (UCLA 31.2 ± 2.7, Rowe 87.1 ± 10.3, Constant 80.9 ± 16.4) and open (UCLA 30.8 ± 0.6, Rowe 87.5 ± 6, Constant 77.2 ± 15.3) stabilization. Recurrent instability, defined as either recurrent subluxation or dislocation was significantly higher with arthroscopic (11.4 ± 2.8%) versus open (4 ± 1.4%) stabilization.Conclusion:Arthroscopic management of anterior glenohumeral microinstability and overt instability allows overhead athletes to return to the same level of play as open stabilization, with similar levels of post-operative ROM and comparable clinical outcomes as measured by validated outcome scores. The higher rate of recurrent instability in overhead athletes following arthroscopic stabilization is similar to current studies in other athletic cohorts (e.g. contact athletes) and warrants further investigation to determine the reasons for this observation.

Tibial avulsion of the posterior cruciate ligament (PCL) often requires operative fixation, which frequently results in successful outcomes if identified acutely. Open or arthroscopic techniques are most commonly used. Primary surgical indications for open fixation include acute tibial avulsion of the PCL. Secondary indications include grade 2 to grade 3 posterior drawer test and radiographic posterior subluxation of the tibia. Ideally, the joint space and articular cartilage should be well preserved. In the simplified approach initially described by Burks and Schaffer, the patient is placed prone, and an inverted L-shaped incision is made over the posteromedial corner of the knee. A plane is developed between the medial head of the gastrocnemius and the semimembranosus down to the knee joint capsule. The gastrocnemius is retracted laterally to protect neurovascular structures and a vertical capsulotomy is performed. The tibial attachment of the PCL is reduced and held with K (Kirschner) wires and then fixated with screw and washer. Six months post operation, our patient achieved full active and passive range of motion with a stable posterior drawer test. He returned to work without difficulty. Multiple studies have shown success with open PCL fixation and decreased rates of arthrofibrosis when compared with arthroscopic approach. In this case, the patient did not develop arthrofibrosis. PCL tibial avulsions can be safely treated with an open approach. Contrary to other ligaments that favor reconstruction over repair, PCL avulsions may be better treated with early repair, so it is important to avoid delay in intervention. The most common complication in both open and arthroscopic approaches is arthrofibrosis, which is less common in the open approach. Early range of motion is encouraged to prevent arthrofibrosis. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background:The treatment of osteochondral lesions of the talus (OLTs) with a juvenile cartilage allograft is a relatively new procedure. Although other treatment options exist for large OLTs, the potential advantage of a particulated juvenile allograft is the ability to perform the procedure arthroscopically or through a minimal approach. No previous studies have looked at the results of an arthroscopic approach, nor have any compared an arthroscopic technique with an open approach.Purpose:To compare the outcomes of an arthroscopic transfer technique with the previously published open technique.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 34 patients (mean age, 33 years) underwent treatment of talar cartilage lesions with a DeNovo NT Natural Tissue Graft. Of these treatments, 20 were performed arthroscopically and 14 were performed with open arthrotomy. There was no statistically significant difference between the groups with respect to age, lesion width, lesion depth, lesion length, or operative time. The mean lesion area was 107 mm2. The scores from 6 different validated outcome measures were recorded for patients in each group preoperatively and subsequently at 6 months, 1 year, 18 months, and 2 years.Results:Comparing outcome scores at each time point to baseline, there were no statistically significant postoperative differences found between open and arthroscopic approaches with regard to the visual analog scale (VAS) for pain (P = .09), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale (P = .17), Foot and Ankle Ability Measure (FAAM)–sports subscale (P = .73), Short Form–12 (SF-12) physical health summary (P = .85), SF-12 mental health summary (P = .91), or FAAM–activities of daily living subscale (P = .76).Conclusion:The treatment of talar articular cartilage lesions with a DeNovo NT Natural Tissue Graft demonstrated no significant differences in outcome at 2 years regardless of whether the graft was inserted with an arthroscopic or open technique.Clinical Relevance:Our analysis demonstrated no significant difference between an arthroscopic versus open approach at any time point for the first 2 years after implantation of a juvenile particulated cartilage allograft for large OLTs. With that said, both groups demonstrated improvement from baseline. These findings indicate that surgeons with different levels of comfort utilizing arthroscopic techniques can offer this treatment modality to their patients without altering their planned surgical approach. In addition, this will be particularly helpful in counseling patients for surgery when the extent of the defect will be evaluated intraoperatively. Patients can be counseled that they will likely have the same incisions regardless of whether they require debridement, microfracture, or implantation of a particulated allograft.

Open Surgical Dislocation vs. Arthroscopic Approach to Femoroacetabular Impingement: A Prospective Comparison (SS-31)

Arthroscopic lateral clavicle resection (LCR) is increasingly used, compared to an open approach, but literature does not clearly indicate which approach is preferable. The goal of this study was to compare function and pain between patients who underwent lateral clavicle resection using an open approach and patients treated using an arthroscopic approach. Patients who underwent LCR between January 2008 and December 2011 were reviewed. After exclusion, 149 shoulders (143 patients) were eligible for analysis: 41 open and 108 arthroscopic. Disabilities of arm, shoulder and hand (DASH) questionnaire and visual analogue scale (VAS) score were used to assess shoulder function and pain. Complications, operative time, length of hospitalization and resection distance were compared. At a mean follow-up of three years, patients in the open group had significantly less pain by VAS (mm) (Mdn 10, IQR 23) compared with arthroscopic patients (Mdn 20, IQR 50) (p = 0.036). Operative time (minutes) was significantly less for the open approach (Mdn 24.0, IQR 12) compared with arthroscopic (Mdn 38.0, IQR 15) (p < 0.001). Resection distance (mm) was larger for the open approach (Mdn 7.1, IQR 7.0) compared with the arthroscopic approach (Mdn 3.2, IQR 3.1) (p = 0.006), but was not associated with outcome. No significant differences were found for DASH score, complication rate or length of hospitalization. Both arthroscopic and open approaches for LCR provide excellent outcome in patients with acromioclavicular pain. Less residual pain was found for the open approach, which has shorter operating time and is likely more cost effective.

PurposeThis study compares the amount of joint preparation and first ray shortening following first metatarsophalangeal (MTP) joint fusion utilizing open conical reaming versus arthroscopic technique.MethodsTen below-knee cadaver specimens were randomly assigned to undergo either open or arthroscopic first MTP fusion. Following fixation, first ray length measurements were obtained from pre-operative and post-operative radiographs and were used to determine first ray shortening. Additionally, the ratio of first ray length to second ray length was calculated both pre-operatively and post-operatively and compared between the two approaches. All ankles were then completely dissected, and prepared surface areas were demarcated. ImageJ photo analysis software (National Institutes of Health, Bethesda, MD, USA) was used to calculate the percentage of prepared and unprepared cartilage of each articular surface of each specimen. ResultsOverall, the open approach resulted in 99.3% ± 1.6% joint surface preparation, whereas the arthroscopic approach yielded 92.9% ± 7.2% (p = 0.089). On average, the head of the first metatarsal was significantly more prepared with the use of the open approach (99.5% ± 1.1%) than with the arthroscopic approach (96.6% ± 1.5%) (p = 0.008). However, with respect to the base of the phalanx, the average difference in preparation between the arthroscopic approach and the open approach was not statistically significant (90.0% ± 12.8% vs. 99.0% ± 2.2%; p = 0.160). The average amount of first ray shortening in the arthroscopic approach was 2.2 ± 1.8 mm compared to 2.1 ± 3.2 mm in the open approach (p = 0.934). The average change in the first to second ray length ratio was 0.02 for both approaches (p = 0.891).ConclusionArthroscopic first MTP fusion can be used to achieve joint preparation comparable to open technique while maintaining first ray length.

Background: Autologous chondrocyte implantation (ACI) is an effective method of repair of articular cartilage defects. It is a 2-stage operation, with the second stage most commonly performed via mini-arthrotomy. Arthroscopic ACI is gaining popularity, as it is less invasive and may accelerate early rehabilitation. However, handling and manipulation of the implant have been shown to cause chondrocyte cell death. Purpose: To assess the number and viability of cells delivered via an open versus arthroscopic approach in ACI surgery. Study Design: Controlled laboratory study. Methods: Sixteen ACI surgeries were performed on young cadaveric knees by 2 experienced surgeons: 8 via mini-arthrotomy and 8 arthroscopically. Live and dead cells were stained and counted on implants after surgery. The cell number and viability were assessed using confocal laser scanning microscopy. Surgery was timed from knife to skin until the end of cycling the knee 10 times after implantation of the cell-membrane construct. Results: On receipt of cell membranes after transportation from the laboratory, ≥92% of the cells were viable. There were significantly more remaining cells (8.47E+07 arthroscopic vs 1.41E+08 open; P < .001) and 16 times more viable cells (3.62% arthroscopic vs 37.34% open; P < .001) on the implants when they were inserted via mini-open surgery compared with the arthroscopic technique. Open surgery was of a significantly shorter duration (6 vs 32 minutes; P < .001). Conclusion: In this study, there were significantly more viable cells on the implant when ACI was performed via mini-arthrotomy compared with an arthroscopic technique. Clinical Relevance: The viability of cells delivered for ACI via an arthroscopic approach was 16 times less than via an open approach. The mini-arthrotomy approach is recommended until long-term clinical comparative data are available.

Introduction: Variably present rotator interval capsular openings (RICOs) complicate anterior shoulder capsular anatomy. Open and arthroscopic approaches may lead to differences in the appearance and size of RICOs. The purposes of this study are to: (1) Confirm that RICOs viewed from inside and outside the joint are the same structures, and (2) compare the size of RICOs when approached in an open manner vs arthroscopically. Materials and methods Twelve fresh cadaveric shoulders were randomized to two different approaches in order to identify and mark RICOs. In the first group, the superior glenohumeral ligament (SGHL) and middle glenohumeral ligament (MGHL) were marked arthroscopically. Sutures were placed in these structures in an open fashion. Repeat arthroscopy was then performed to determine whether the sutures penetrated the marked SGHL and MGHL. In the second group, these steps were reversed and arthroscopically placed sutures were evaluated in an open manner. Dimensions of the RICOs were measured both arthroscopically and open in each shoulder. Results All specimens had a RICO visualized both arthroscopically and open. Five of 12 specimens had an additional second RICO. RICO size measurements were similar for the arthroscopic and open techniques. Sutures placed via both the arthroscopic and open technique were noted to penetrate the marked structures in all cases. In addition, sutures placed through the SGHL while viewing arthroscopically always captured the coracohumeral ligament (CHL). Sutures placed through the SGHL with an open technique never engaged the CHL. Conclusion The capsular openings in the rotator interval were confirmed to be the same structures when observed arthroscopically and through an open approach. Svoboda SJ, Taylor DC, Magnussen RA. The Anatomic Variability of the ‘Rotator Interval Capsule’: A Comparison of Arthroscopic and Open Investigations. The Duke Orthop J 2013;3(1):54-60.

Background:Whether arthroscopic or open surgical management for diffuse-type tenosynovial giant cell tumor (D-TGCT) of the knee is associated with a lower rate of recurrence is unknown.Methods:PubMed, Scopus, Web of Science, Cochrane, and EMBASE were searched on December 3, 2020. Retrospective studies that reported on recurrence rates for arthroscopic versus open management of D-TGCT were included. A total of 16 studies evaluating 1143 patients with D-TGCT of the knee were included (nopen = 551, narthroscopic = 350 patients, and narthroscopic/open = 23 patients). Random-effects meta-analyses were used to summarize and compare the reported recurrence rates, stratified by approach and overall recurrence. The meta-analysis was registered with PROSPERO.Results:The recurrence rate per year (incidence) for arthroscopic procedures was 0.11 (95% CI 0.08 to 0.16, P < 0.0001) and for open procedures was 0.07 (95% CI 0.04 to 0.13, P < 0.0001). There was a 1.56 times (95% CI 1.04 to 2.34, P = 0.0332) increased risk of recurrence when treating D-TGCT of the knee with an arthroscopic approach. When evaluating only the subset of studies that had data for both arthroscopic and open approaches, the incidence rate per year for arthroscopic procedures was 0.17 (95% CI 0.11 to 0.27, P < 0.0001) and for open procedures was 0.11 (95% CI 0.06 to 0.19, P < 0.0001). The rate of overall complications was 0.04 (95% CI 0.01 to 0.08, P < 0.0001).Conclusion:Arthroscopic surgical management of D-TGCT of the knee in our study resulted in a 1.56 times risk of recurrence as compared with the open approach. The percent of overall complications was minimal.

Patients with intra-articular gunshot wounds (GSWs) are presenting with increasing frequency at many trauma centers. These injuries necessitate a specific treatment regimen that includes a thorough irrigation and debridement as well as surgical exploration of the joint, typically through an open approach. The bullet must be removed from the joint because retained bullets and clothing material in joints can cause several complications, including mechanical symptoms, damage to the articular cartilage1, posttraumatic arthritis2, and, rarely, lead poisoning3. Access to the sacroiliac (SI) joint can be challenging given its location and proximity to surrounding vital structures. An open anterior ilioinguinal approach with use of the lateral window technique can increase blood loss and morbidity. The posterior approach to the SI joint allows for limited intra-articular access and has increased rates of wound complications4. Open approaches carry a theoretical increased risk of wound complications (e.g., infection, hematoma, and dehiscence) and can also be very time-consuming. The exposure and closure in cases where the SI joint needs to be exposed are extensive. Although arthroscopic surgery can be more costly, it affords the patient the advantage of a smaller wound, decreased morbidity at the surgical site, and potentially a decreased length of hospital stay5. For these reasons, percutaneous approaches are gaining favor over open approaches. In 2008, Lee et al. were the first to describe the arthroscopic approach to the SI joint utilizing solely a bullet track6. This technique used one guidewire that was drilled through the bullet for extraction. In our case report, we describe the surgical technique that was used to perform an arthroscopically assisted bulletectomy from the SI joint with use of a dual guidewire technique via the bullet track with arthroscopic as well as fluoroscopic guidance. The patient and …