Arthroscopic Arthrolysis Research Articles

Arthrofibrosis of the hip joint : Diagnostic and therapeutic challenge

Arthrofibrosis is afrequent complication after total knee arthroplasty (TKA). Recently, arthrofibrosis could be successfully verified histologically after primary total hip arthroplasty (THA) and the clinical presentation on the hip could be described for the first time. Possible diagnostic and therapeutic approaches have not yet been published. The diagnostic work-up differs only slightly from that for the knee joint. Other causes, such as aseptic loosening, malalignment or periprosthetic joint infection should be excluded. The gold standard is still invasive diagnostics with histological evidence of arthrofibrosis according to the synovia-like interface membrane (SLIM) criteria. Conservative treatment approaches include mobilization under anesthesia and medication according to Traut, analogous to the knee joint. Surgical treatment should be carried out under strict interpretation of the indications and after detailed clarification for the patient. In contrast to the knee joint, open arthrolysis should be preferred to arthroscopic arthrolysis of the hip joint. It must be taken into consideration that the evidence for conservative as well as surgical treatment, including possible revision arthroplasty, cannot be assessed due to the absence of clinical data. Studies under controlled conditions on the possible treatment approaches in the presence of arthrofibrosis are desirable and necessary in order to be able to assess the significance of the symptoms. In addition to treatment, great importance should also be attached to the diagnostics. Histological confirmation of the diagnosis of arthrofibrosis should only be considered to alimited extent in the case of an assumed, only moderately successful surgical intervention.

Failure of primary ACL repair with dynamic intraligamentary stabilization may result in a high risk of two-stage ACL reconstruction: a case series of ten patients

PurposeDynamic Intraligamentary Stabilization (DIS) is a technique for the repair of acute anterior cruciate ligament (ACL) injuries. The purpose of this study was to investigate the potential challenges of ACL reconstruction (ACLR) following failure of DIS.MethodsA retrospective analysis of patients with failure of primary ACL repair performed with DIS was undertaken. Failure was defined as abnormal knee laxity (positive Lachman and/or pivot shift) and/or severely restricted range of motion. Medical and surgical records were reviewed and preoperative standard anteroposterior and lateral X-rays were assessed.ResultsBetween July 2015 and May 2022, 10 patients (3 males, 7 females, median age 28 years, range 18–52 years) with failure of DIS were referred to and surgically treated at a single centre. In four patients, single-stage ACLR was performed following the removal of the tibial monoblock. In six patients, arthrofibrosis and excessive tibial tunnel enlargement following the removal of the monoblock prevented single-stage ACLR. These patients underwent arthroscopic arthrolysis and tibial tunnel bone grafting as a first-stage revision procedure.ConclusionIn the present case series, single-stage ACLR was performed in only four (40%) of ten patients following failure of ACL repair with DIS. Arthrofibrosis and excessive tibial tunnel enlargement following the removal of the monoblock prevented single-stage ACLR in six (60%) patients. It is important for clinicians to inform patients that, in the event of failure of ACL repair with DIS, they may run a high risk of undergoing two-stage ACLR.Level of EvidenceLevel IV, Case Series.

Is combined robotically assisted unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction a good solution for the young arthritic knee?

Anterior cruciate ligament (ACL) deficiency can be a consequence or a cause of femoro-tibial osteoarthritis (OA). Several studies have published satisfactory outcomes of unicompartimental knee arthroplasty (UKA) and combined ACL reconstruction despite its absence classically being considered a contraindication. A major challenge in the ACL deficient knee is obtaining appropriate gap balancing and limb axis. Robotically assisted UKA allows for precise control of these factors; however, it's utilisation as a tool with combined ACL reconstruction and UKA has not been described. The purpose of this study was to evaluate the clinical and radiological outcomes of robotically assisted UKA with combined ACL reconstruction. This was a retrospective single-centre study of ten patients operated by a single surgeon from 2016 to 2020. All surgery was performed using a cemented fixed bearing UKA prosthesis (Journey uni, Smith and Nephew®) (8 medial, 2 lateral) inserted with the assistance of an image-free robotic-assisted system (BlueBelt, Navio, Smith and Nephew®). All ACL reconstructions were performed using hamstring autograft. Clinical assessment included International Knee Score (IKS) score, Tegner score and patient satisfaction. Radiological assessment was performed to assess radiolucent lines, progression of OA in the other compartments, Hip-Knee-Ankle angle and Posterior Tibial Slope. There were eight females (80%), mean age was 57 ± 7 [48-70], mean BMI was 26 ± 3 [22-31]. The mean follow-up was 45months ± 13months [24-66]. Mean post-operative IKS knee and function score were respectively 96 ± 4.5 [88-100] and 93 ± 8.2 [74-100], mean Tegner score was 4.5 ± 1.4 [3-6]. Nine patients (90%) returned to sport; one patient (10%) was dissatisfied because of residual pain preventing a return to a desired level of sport. 100% of the radiological objectives were achieved. No radiolucent lines were seen at the last follow-up. There were two re-operations (20%) for stiffness requiring arthroscopic arthrolysis at two and threemonths respectively following surgery, with full recovery of the flexion at the last follow-up in both cases. No other complications were observed. Robotic UKA associated with ACL reconstruction provides satisfactory early patient outcomes and accurate implant positioning. The first results in terms of return to sports were promising.

Easy Arthroscopic Transseptal Approach of the Knee

Background: The arthroscopic approach to the posterior compartment of the knee is always challenging. This easy arthroscopic transseptal approach allows safe access to the posterior compartment of the knee, avoiding any potential neurovascular injury. Indications: Indications include arthroscopic posterior cruciate ligament (PCL) reconstruction, fixation of avulsion fractures of the tibial attachment of the PCL, arthroscopic posterolateral corner reconstruction, removal of loose bodies from the posterior compartment, PCL cyst removal, ramp repair, and arthroscopic arthrolysis of the posterior compartment. Technique Description: Using a posteromedial portal, a shaver is introduced with the tip in direct contact with the medial side of the septum facing anteriorly, away from the popliteal neurovascular bundle. The scope is then inserted into the posterolateral compartment to visualize the lateral side of the septum while the shaver remains in the posteromedial compartment. The septum is then released until the tip of the shaver is visible. The shaver is then removed and the scope can now be inserted from the posteromedial portal to the posterolateral compartment through the released septum. Results: The transseptal approach can be performed without any additional risk if the shaver remains centrally on the inferior aspect of the septum. Therefore, the risk of iatrogenic injury of the middle genicular artery is minimized. Likewise, with the knee flexed to 90°, there is no risk of damaging the popliteal neurovascular bundle. Having a precise knowledge of the anatomy of the posterior compartment of the knee minimizes any risks of the transseptal approach, avoiding any additional surgical time whilst facilitating the indicated operation. Conclusion: This easy arthroscopic transseptal approach allows safe access to the posterior compartment of the knee, avoiding any potential neurovascular injury.

Surgical arthrolysis of the stiff elbow: a systematic review

IntroductionStiffness after elbow injuries can severely limit daily life. If adequate conservative treatment does not result in satisfactory improvement of elbow function, surgical intervention should be considered. Whether an open or arthroscopic procedure is preferable is still a topic of debate and a systematic review of functional outcomes is lacking.Materials and methodsWe systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and EMBASE, for studies published between 2013 and 2021. Primary objective was to compare open and arthroscopic arthrolysis’ functional outcomes, respectively, especially ROM and MEPS, as well as the accompanied complications. The PRISMA guidelines were applied.Results27 studies comprising 1666 patients were included. 1059 patients (63.6%) were treated with open arthrolysis, and 607 patients (36.4%) were treated with arthroscopic arthrolysis. The results presented indicate satisfactory outcomes in open and arthroscopic arthrolysis with regard to functional outcome parameters. Treatment success, defined as excellent or good results according to the Mayo Elbow Performance Score, among the patients treated with an open procedure was 88.8%; 6.3% required revision whereas 18.1% had complications without the need for revision surgery. Within the cohort of arthroscopically treated patients, treatment success was 91.8%. Revisions and complications without further surgical intervention were significantly less frequent than in the open cohort, at 1.6% and 9.1%, respectively.ConclusionsBoth open and arthroscopic arthrolysis provide good to excellent functional outcomes. Since the number of complications and revision increases with the invasiveness of the treatment, an arthroscopic procedure might be favored if feasible by indication. The role of forearm rotation and the use of a hinged external fixator remains of interest.Study designLevel IV; Systematic review.

Dislocation Arthropathy of the Shoulder.

Glenohumeral osteoarthrosis (OA) may develop after primary, recurrent shoulder dislocation or instability surgery. The incidence is reported from 12 to 62%, depending on different risk factors. The risk of severe OA of the shoulder following dislocation is 10 to 20 times greater than the average population. Risk factors include the patient’s age at the first episode of instability or instability surgery, bony lesions, and rotator cuff tears. For mild stages of OA, arthroscopic removal of intraarticular material, arthroscopic debridement, or arthroscopic arthrolysis of an internal rotation contracture might be sufficient. For severe stages, mobilization of the internal rotation contracture and arthroplasty is indicated. With an intact rotator cuff and without a bone graft, results for anatomical shoulder arthroplasty are comparable to those following primary OA. With a bone graft at the glenoidal side, the risk for implant loosening is ten times greater. For the functional outcome, the quality of the rotator cuff is more predictive than the type of the previous surgery or the preoperative external rotation contracture. Reverse shoulder arthroplasty could be justified due to the higher rate of complications and revisions of non-constrained anatomic shoulder arthroplasties reported. Satisfactory clinical and radiological results have been published with mid to long term data now available.

Outcomes of Mini-Invasive Arthroscopic Arthrolysis Combined with Locking Screw and/or Intramedullary Nail Extraction after Osteosynthesis of the Proximal Humerus Fracture.

Data on the effectiveness of arthroscopic arthrolysis and extraction of osteosynthetic material after osteosynthesis of the proximal humerus in patients with persisting problems are rare and insufficient. In this study, we performed arthroscopic arthrolysis and extraction of fixation screws, and, where protruding, extraction of the nail in 34 patients with problems persisting 12 months after osteosynthesis of the proximal humerus using an intramedullary nail. The effectiveness of the treatment was assessed using the Constant–Murley shoulder score and forward flexion difference between the treated arm and the contralateral one. A median increase of 16 points in CMS score and 30 degrees reduction in the arm forward flexion difference was recorded 12 months after the arthroscopy. The improvement was significantly higher in the patient group with intramedullary nail extraction (however, this group had worse pre-operative values and the screw was only extracted where likely to cause problems). The median time to heal was 11 weeks; no serious peri- or post-procedural complications occurred. Mini-invasive arthroscopic arthrolysis combined with extraction of osteosynthetic material proved to be a safe and effective method for treatment of patients after osteosynthesis of the proximal humerus using an intramedullary nail with persisting pain and/or mobility limitation.

Combined procedures with unicompartmental knee arthroplasty: High risk of stiffness but promising concept in selected indications

Introduction: Unicompartmental knee arthroplasty (UKA) has traditionally been contraindicated in the presence of an ACL deficient knee, bi-compartmental disease, or significant coronal deformity due to concerns regarding increased risk of persisted pain, knee instability, tibial loosening, or progression of osteoarthritis. The aim of this study was to evaluate the outcomes of patients undergoing UKA with an associated surgical procedure in these specific indications. Method: This was a retrospective cohort study of patients undergoing UKA between December 2015 and October 2020. Patients were categorized into groups based on associated procedures: UKA + ACL, UKA + HTO, and bicompartmental arthroplasty. Outcomes were assessed using the Knee Society Score (KSS) knee and function scores and the Forgotten Joint Score. Radiological and complication analysis was performed at the last clinical follow-up. Results: Thirty-two patients (13 men and 19 women) were included. The mean age was 56.2 years ± 11.1 (range, 33–84) with a mean follow-up of 26.3 months ± 15 (7.3–61.1). There was a significant improvement between the pre-and postoperative KSS Knee (+34.3 ± 16.5 [12–69]), Function (+34.3 ± 18.6 [0–75]), and Total scores (+68.5 ± 29.4 [24–129]) (p = 0.001). Seven patients (21.8%) required an arthroscopic arthrolysis for persistent stiffness. Two patients (UKA + PFA and UKA + ACL) underwent revision to TKA. Patient satisfaction was 90%, and mean flexion at last follow-up was 122° ± 6 (120–140). The implant survival rate was 94%. Discussion: This study found performing UKA with an additional procedure to address relative contraindications to the arthroplasty in physically active patients with monocompartmental knee arthritis is an efficient strategy with good results at short-term follow-up. It should be reserved for patients where TKA is likely to have unsatisfactory results, and the patient has been fully counseled regarding the management options. Even if there is a high rate of complications with stiffness requiring a re-intervention, the final results are very satisfying with no impact of the reintervention on the clinical result in the short term.

Reconstructive surgeries and endoprosthetics of the elbow joint: indications, possibilities and prospects

BACKGROUND: Severe injuries of the elbow joint and their consequences are a serious problem in modern traumatology and orthopedics due to the large number of unsatisfactory treatment results, in particular, due to the lack of a differentiated approach to the choice of tactics and the method of surgery.
 AIM: To evaluate the results of a differentiated approach to the choice of tactics and the method of surgical intervention in the treatment of patients with injuries and consequences of injuries of the elbow joint.
 MATERIALS AND METHODS: The results of treatment of 245 patients with injuries and consequences of damage to the elbow joint were assessed within 11 years from the date of surgery. Six groups of patients were identified: group 1 osteosynthesis of fractures of the elbow joint; 2nd open arthrolysis without the imposition of Oganesyans hinged distraction apparatus (HDA); 3rd open arthrolysis with the imposition of HDA; 4th arthroscopic arthrolysis without HDA imposition; 5th arthroscopic arthrolysis with the imposition of HDA; 6th elbow arthroplasty.
 RESULTS: In 93% of patients after osteosynthesis (1st group of patients), a good result was obtained (the deficit in the range of motion was not more than 10, the average score on the DASH scale was 8). In patients after arthrolysis, there is a twofold increase in the range of motion (on average from 4250 to 114120), and regardless of the method of arthrolysis (arthroscopic or open) and whether HDA was used or not. On the DASH scale, 89% of patients showed a decrease in points on average from 77 to 36. In the 6th group, an increase in the range of motion was noted on average from 4548 to 126135, on the DASH scale a decrease in points from 7982 to 3944 on average. Revision intervention was required in 28.4%.
 CONCLUSION: The choice of the method of surgical treatment of injuries and the consequences of severe injuries of the elbow joint directly depends on the degree and nature of destruction of the bone-articular and soft tissue structures, the deficit in the range of motion in the joint.

Stiffness After Total Knee Arthroplasty: Prevalence and Treatment Outcome

IntroductionStiffness following total knee arthroplasty (TKA) is an incapacitating complication. The prevalence and causes leading to stiffness are not clearly determined. The aim of the study was to ascertain the prevalence, determine the influencing factors, and evaluate the efficacy of manipulation under anaesthesia (MUA) as a treatment option.MethodRetrospective review of consecutive series of 1350 primary TKA over a 28-month period. For the purpose of the study, stiffness was defined as flexion contracture of >15 degrees and/or flexion of <75 degrees. Demographic data included co-morbidities, previous knee surgery, pre-operative and post-operative range of movement, anaesthetic techniques and use of nerve blocks, type of prosthesis, ligament balancing including release, mobility post-surgery, patient motivation, physiotherapy, complications, and final range of motion post-MUA.ResultsOf the 1350 patients evaluated, 33 (2.44%) had stiffness defined by the above-outlined criteria and required intervention. Thirty-one patients (2.29%) underwent MUA as a first-line treatment. No complications arose following MUA. One patient (0.07%) required arthroscopic arthrolysis while another patient (0.07%) required revision arthroplasty due to patellar mal-tracking. Following manipulation, mean flexion contracture decreased from 8 degrees to 3.6 degrees, and mean flexion improved from 51.8 degrees to 93.2 degrees. Arc of motion improved in 100% of patients but it is important to note that multiple manipulations were performed in seven patients.ConclusionStiffness after TKA can be difficult to treat and can result in prolonged morbidity and dissatisfaction. This retrospective study highlights the effectiveness of manipulation under anaesthesia as a first-line treatment option leading to improved outcomes especially if done early.

Clinical results after very early, early and late arthroscopic arthrolysis of the knee

PurposeImpaired patient outcome can be directly related to a loss of motion of the knee following surgical procedures. If conservative therapy fails, arthroscopic arthrolysis is an effective procedure to improve range of motion (ROM). The purpose of this study was to evaluate the outcome of patients undergoing very early (< 3 months), early (3 to 6 months), and late (> 6 months) arthroscopic arthrolysis of the knee.MethodsWith a follow-up on average at 35.1 ± 15.2 (mean ± SD, 24 to 87) months, 123 patients with post-operative motion loss (> 10° extension deficit/ < 90° of flexion) were included between 2013 and 2018 in the retrospective study, while eight patients were lost to follow-up. A total of 115 patients were examined with a minimum follow-up of two years. Twenty percent (n = 23) of patients of this study population had a post-operative motion loss after distal femoral fracture, 10.4% (n = 12) after tibial head fracture, 57.4% (n = 66) after anterior/posterior cruciate ligament (ACL/PCL) reconstruction, 8.7% (n = 10) after infection of the knee, and 3.4% (n = 4) after patella fracture. Thirty-seven patients received very early (< 3 months, mean 1.8 months) arthroscopic arthrolysis, and 37 had early (3 to 6 months, mean 4.3 months) and 41 late (> 6 months, mean 9.8 months) arthroscopic arthrolysis after primary surgery.ResultsThe average ROM increased from 73.9° before to 131.4° after arthroscopic arthrolysis (p < 0.001). In the group of very early (< 3 months) arthroscopic arthrolysis 76% (n = 28) of the patients had a normal ROM (extension/flexion 0/140°), in the group of early (3–6 months) arthrolysis 68% (n = 25) of the patients and in the group of late arthrolysis 41.5% (n = 17) of the patients showed a normal ROM after surgery (p = 0.005). The total ROM after arthrolysis was also significantly increased in the group of very early and early arthrolysis (136.5° and 135.3° vs. 123.7°, p < 0.001). A post-operative flexion deficit occurred significantly less in the group of very early and early arthroscopic arthrolysis compared to the late arthroscopic arthrolysis (3.9° and 4.2° vs. 16.6°, p < 0.001). Patients treated with very early (< 3 months) and early (3 to 6 months) showed a significantly increased post-operative Tegner score of 4.8 ± 1 and 4.7 ± 1.1 compared to 3.8 ± 1.1 in the group of late arthroscopic arthrolysis (> 6 months, p < 0.001).ConclusionsAn arthroscopic arthrolysis is highly effective and leads to good to excellent mid-term results. An early arthroscopic arthrolysis within 6 months after primary surgery leads to significantly improved ROM and functional scores compared to the late arthrolysis (> 6 months).

Wrist Arthrolysis: A Systematic Review of Open and Arthroscopic Techniques.

Background Wrist arthrolysis is a viable option in wrist stiffness and can be performed via open or arthroscopic techniques. Purpose The aim of the study is to describe and evaluate the available techniques of open and arthroscopic arthrolysis of the radiocarpal joint and the distal radio ulnar joint (DRUJ) in posttraumatic wrist stiffness. Methods A systematic literature search was performed in PubMed to identify studies reporting on open and arthroscopic wrist arthrolysis. Key words included "open wrist arthrolysis," "arthroscopic wrist arthrolysis," "post-traumatic wrist stiffness," and "DRUJ arthrolysis." Data were extracted independently by a pair of reviewers. Results Overall, 637 studies were identified; 13 additional articles were found through previous publications (total 650 articles). A total of 612 records resulted after duplicates was removed. Fourteen studies were selected and only eight respected the inclusions criteria. One study focused on volar open arthrolysis and four studies on arthroscopic arthrolysis of the radiocarpal joint; two studies reported on open arthrolysis and two studies on arthroscopic DRUJ arthrolysis. Range of motion following open and arthroscopic wrist arthrolysis improved in all studies. Conclusion Both arthroscopic and open arthrolysis can lead to similar and satisfactory results in radiocarpal joint and DRUJ stiffness.. Level of Evidence This is a level 3a study.

Anatomical repair and ligament bracing of Schenck III and IV knee joint dislocations leads to acceptable subjective and kinematic outcomes

PurposeThe aim of this study was to analyze the outcomes of anatomical repair and ligament bracing for Schenck III and IV knee dislocation (KD).MethodsThe results of 27 patients (15 and 12 cases of Schenck III and IV KD, respectively) after a mean follow-up of 18.1 ± 12.1 months (range 6–45 months) were retrospectively reviewed. Twenty-two patients suffered high-kinetic-energy accidents, whereas five patients suffered ultralow-velocity (ULV) trauma due to obesity. The outcome measures were the Lysholm score, Hospital for Special Surgery (HSS) knee score, Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Short Form 36 (SF-36) score. A kinematic 3D gait analysis with five walking trials was performed to compare the patients and healthy controls.ResultsThe mean KSS, HSS score, Lysholm score, and KOOS were 77.4 ± 14.4, 84.6 ± 11.2, 81.5 ± 10.4, and 67.3 ± 16.8, respectively. No intra- or postoperative complications occurred. The mean range of motion deficiency compared to the healthy side was 24.4 ± 18.5°. Ten patients had first-degree residual laxity of the anterior cruciate ligament; 12 and 2 patients had first- and second-degree residual laxity of the collateral ligament, respectively. Five patients underwent additional arthroscopic arthrolysis due to arthrofibrosis at an average of 6.2 ± 1.9 months (range 4–9 months) after the initial surgery. The 3D gait analysis showed no major differences in joint stability or movement between the patients and healthy controls. Only the ULV trauma patients had significantly lower outcome scores and showed larger kinematic deviations in joint movement during the gait analysis.ConclusionAnatomical repair with ligament bracing is a suitable surgical procedure in the treatment of KD and provides evidence in clinical practice with the benefit of early, definitive repair and preservation of the native ligaments. Patients reach acceptable subjective and objective functional outcomes, including mainly normalized gait patterns during short-term follow-up, with only minor changes in kinematics and spatial–temporal characteristics. Obese patients who suffered ULV trauma showed significantly inferior outcomes with larger deviations in joint kinematics.Level of evidenceLevel III.

Posttraumatische Schultersteife

Posttraumatic stiffness of the shoulder joint is a frequent and socioeconomically relevant result of injury; however, prior to making the diagnosis as the only cause of a persisting impairment of motion, it is necessary to rule out other sequelae of trauma. Even intensive conservative treatment is mostly accompanied by the stagnation of the impairments of movement. In many cases the treatment of choice is early arthroscopic arthrolysis with a standardized approach and intensive follow-up treatment. In the surgical treatment of proximal humeral fractures with humeral head preservation, arthroscopic arthrolysis with simultaneous implant removal is a form of planned second intervention for improvement of shoulder function in cases of persisting motion deficits after bony consolidation. Despite sometimes substantial limitations of movement, a clinically relevant and lasting improvement of shoulder function can be achieved with arthroscopic arthrolysis in posttraumatic shoulder stiffness.

Arthroscopic Debridement and Arthrolysis for the Treatment of Advanced Kienböck's Disease: 18-Month and 5-Year Postoperative Results

Background Salvage procedures, such as proximal row carpectomy, limited or total wrist arthrodesis, and wrist replacement, are generally preferred to treat advanced Kienböck's disease. However, these procedures are particularly aggressive and may have unpredictable results and potentially significant complications. Questions/Purpose This study aimed to present the short- to mid-term clinical and functional results of arthroscopic debridement and arthrolysis in the management of advanced Kienböck's disease. Patients and Methods Fifteen patients in whom Lichtman Stages IIIA to IIIC or IV Kienböck's disease was diagnosed and treated by arthroscopic wrist debridement and arthrolysis were included in this retrospective study. The mean age was 30 years (range: 21-45). The mean follow-up period duration was 36 months (range: 18-60). The Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS), wrist range of motion (ROM), and grip strength were measured preoperatively and then again at the final follow-up visit. Results The mean DASH and VAS scores improved from 41 (range: 31-52) and 7.1 (range: 6-8) preoperatively to 13 (range: 8-21) and 2 (range: 0-3; p < 0.001) at the final follow-up visit, respectively. The mean wrist flexion and extension values increased from 32 (range: 20-60 degrees) and 56 degrees (range: 30-70 degrees; p = 0.009) preoperatively to 34 (range: 10-65 degrees; p = 0.218) and 57 degrees (range: 30-70 degrees; p = 0.296) at the final follow-up appointment, respectively, although these findings were statistically insignificant. The mean strength of the hand grip increased from 22.7 (range: 9-33) to 23.3 (range: 10-34; p = 0.372). Conclusion Arthroscopic debridement and arthrolysis may improve wrist function and quality of life due to the preserved ROM and hand grip strength after short- to mid-term follow-up periods despite the radiographic progression of Kienböck's disease. Level of Evidence This is a Level IV, retrospective case series study.

Hidden instability in posttraumatic stiff elbows.

Hidden instability could be one of the reasons for reoccurring stiffness after arthrolysis in posttraumatic elbows. Associated instability in stiff posttraumatic elbows is clinically hard to detect. Surgical treatment for instability and stiffness in the same surgical setting is challenging and has not been evaluated as of yet. The primary hypothesis assumes (1) the existence of a posttraumatic "stiff and unstable elbow" and (2) that coexisting instability can be detected by arthroscopic instability testing. The secondary objective was to report the midterm results after arthrolysis and ligament stabilization in the stiff and unstable elbow. From 2005 to 2015, 55 patients received arthroscopic arthrolysis of the elbow due to posttraumatic elbow stiffness at our institution. The arthroscopic instability was categorized into three grades with a switching stick: grade I (= stable), grade II (mild instability) and grade III (grossly instable). In cases of persisting instability (grade II-III), a ligament stabilization procedure was performed and all patients were followed up clinically at a minimum of 12months. Besides ROM and clinical joint stability, PROs (patient reported outcomes) were assessed with the PREE-score (patient-rated elbow evaluation) and the Oxford-Elbow-score (OES). Furthermore, the MEPS (Mayo-elbow-performance-score) was assessed. Out of 55 cases presenting for arthrolysis, coexisting elbow instability was detected during arthroscopic instability testing in 22 cases (40%). All 22 patients received additional ligament stabilization. At final follow-up 62.7 ± 35.7months postoperatively, 20 patients (12 men; 8 women) with a mean age of 42 ± 16.8 were available. PREE, OES and MEPS were 19.8 ± 25.3, 37.5 ± 9.8 and 80 ± 14.5, respectively. ROM improved significantly from 95° ± 29° to 110° ± 24° postoperatively (p = 0.045). Five patients required revision arthrolysis within the follow-up period (20%). One patient demonstrated persisting instability (5%). Intraoperative instability diagnostics during arthroscopic arthrolysis helps detect persisting posttraumatic instability and may provide a solid indication for a concurrent ligament stabilization procedure. This study is the first to present the postoperative results after arthrolysis with stabilization of the posttraumatic, stiff and unstable elbow. However, the results are heterogenic with 25% requiring revision arthrolysis. Therefore, the stiff but unstable elbow remains a complex clinical presentation in need of further investigations. IV.

Stiffness after unicompartmental knee arthroplasty: Risk factors and arthroscopic treatment.

Introduction: One of the principal complications after total knee arthroplasty (TKA) is stiffness. There are no publications concerning stiffness after unicompartmental knee arthroplasty (UKA). Study objectives were to describe the incidence of stiffness after UKA, to look for risk factors, and to describe safe and effective arthroscopic treatment. Methods: There were 240 UKA performed between March 2016 and January 2019 included. Robotic-assisted surgery was performed in 164 patients and mechanical instrumentation in 76 patients. Stiffness was defined as flexion < 90° or a flexion contracture > 10° during the first 45 post-operative days. Patients with stiffness were treated with arthroscopic arthrolysis. Several factors were studied to look for risk factors of stiffness: body mass index, gender, age, mechanical or robotic instrumentation, preoperative flexion, previous meniscectomy, and anticoagulant treatment. Arthrolysis effectiveness was evaluated by flexion improvement and UKA revision rate. Results: 22 patients (9%) developed stiffness. Mechanical instrumentation significantly increased the risk of stiffness with OR = 0.26 and p = 0.005. Robotic-assisted surgery decreased the risk of stiffness by five-fold. Before arthrolysis, mean knee flexion was 79°, versus 121° (53% improvement) after arthroscopic arthrolysis. Only 2 patients (9%) underwent UKA revision after arthrolysis. Discussion: Stiffness after UKA is an important complication with an incidence of 9% in this study. Arthroscopic arthrolysis is a safe and effective treatment with a range of motion improvement of > 50%. Robotic-assisted surgery significantly decreases the risk of postoperative stiffness.Level of evidence: Level III, therapeutic study, retrospective cohort study

SURGICAL TREATMENT OF THE KNEE JOINT CONTRACTURES AFTER TOTAL KNEE ARTHOPLASTY

Background: The development of contractures after total knee replacement is most often associated with arthrofibrosis and makes up 1.3% - 5.7% of the total number of cases of joint replacement. Conservative treatment is ineffective. Arthrolysis is pathogenetically substantiated (arthroscopic or open).&#x0D; Aims: assessment of the effectiveness of arthrolysis as a method of treating knee joint contractures after arthroplasty, comparison of the results of arthroscopic and open arthrolysis, analysis of complications.&#x0D; Materials and methods: Compare two groups. In group 1, 57 patients underwent arthroscopic arthrolysis. In group 2, 54 patients underwent open arthrolysis. The operations were performed from 2015 to 2019, the observation period ranged from one year to three years. As criteria for the result of treatment, KSS data were used (general and functional assessment of the knee joint), as well as separately the amplitude of movements in the joint before surgery and at different times after it.&#x0D; Results: One of the results of this work was the optimization of arthroscopic arthrolysis technique. Improved surgical access and joint revision sequence. According to the KSS scale and range of motion, the best results were obtained in group 1. Especially important is the lesser number of complications in comparison with the 2nd group requiring repeated interventions, including revision arthroplasty. In the 1st group of such cases there were 3 (5.3%), in the 2nd group - 7 (13.0%).&#x0D; Conclusions: Arthroscopic arthrolysis is a less traumatic and more effective treatment for arthritis of the knee. It seems appropriate to gradually displace open arthrolysis by arthroscopic.

Staged meniscal allograft transplantation as a biologic treatment of the meniscal deficient knee: A prospective case series of 26 patients with maximum 88-month follow-up

IntroductionThe meniscal deficient knee often exists within the setting of associated pathology including instability, malalignment and chondral injury. The aim of this study was to establish the role of meniscal allograft transplantation (MAT) as part of a staged approach to treatment of the previously menisectomised knee and report: (a) primary data endpoints (pre and post-operative Knee Injury and Osteoarthritis outcome scores (KOOS), Tegner scores, satisfaction scores and graft survival), and (b) secondary endpoints:(complication/reoperation rates, and meniscal extrusion measurements as determined by MRI). Material and methodsThis prospective study included all patients that underwent arthroscopic fresh frozen allograft MAT at our institution (2010–2017) using a soft tissue fixation technique. ResultsTwenty-seven MAT procedures were performed in 26 patients (16 lateral, 11 medial). Ten patients underwent ACL reconstruction, three ACI and two osteotomy in the pre-MAT phase. Seven patients underwent ACI within the post-operative phase. Post-operative mean KOOS scores improved significantly in all subscales (p < .002) as did Tegner scores (p < .05). Graft survival was 100%, satisfaction rate 92%, and mean meniscal extrusion 3.04 mm. Post operatively, three patients required meniscal repair and a single patient, partial menisectomy of graft. Two patients underwent arthroscopic arthrolysis following MAT. ConclusionsThis series highlights the multifactorial profile of the meniscal deficient knee and the role of MAT as a safe and reliable technique in the staged and comprehensive biologic treatment available to minimise symptoms and maximise outcomes.Level of evidence: 4.

Arthroscopic arthrolysis leads to improved range of motion and health-related quality of life in post-traumatic elbow stiffness

Post-traumatic elbow stiffness is a frequent and disabling complication after elbow trauma. Surgical release is needed if conservative treatment fails. In contrast to open surgical release, arthroscopic arthrolysis is a good and least invasive option to restore joint mobility. The aim of this study was to evaluate the clinical outcomes, range of motion (ROM), and function of post-traumatic elbow contracture after arthroscopic arthrolysis and to assess health-related quality of life (HRQL). Between 2007 and 2013, 44 patients with post-traumatic elbow stiffness were treated by arthroscopic arthrolysis and followed up in a consecutive series. Clinical (ROM) and functional analyses (Disabilities of the Arm, Shoulder, and Hand Questionnaire [DASH], Mayo Elbow Performance Index [MEPI]) were performed at final follow-up 3 (1-7) years postoperatively. Furthermore, HRQL was evaluated (EQ-5D, 36-Item Short Form Health Survey [SF-36]). The average arc of elbow motion increased from 84° ± 28° preoperatively to 120° ± 18° postoperatively. All applied scores significantly improved pre- to postoperatively: the MEPI (59.8 ± 17.3 / 84.3 ± 14.0), DASH (43.5 ± 23.1 / 16.8 ± 15.6), EQ-5D (72.8 ± 16.6 / 84.0 ± 13.6), and SF-36 showed improved results in all categories. Univariate logistic regression revealed that preoperative pain level predicts a poorer postoperative outcome measured with the MEPI score. Revision arthroscopy was needed in 1 case because of persistent pain. Arthroscopic arthrolysis leads to good clinical and functional results in post-traumatic elbow stiffness regarding ROM, pain relief, functionality, and quality of life. The complication rate as well as the revision rate is very low.