Arthroscopic Exploration Research Articles

Arthroscopic Management of an Extremely Rare Wrist Fracture-Dislocation Pattern

Abstract Background Axial dislocation involves the displacement of carpal bones along the longitudinal axis of the wrist joint. There are three major groups: (1) axial ulnar, (2) axial radial, and (3) combined. On the other hand, radiocarpal dislocation entails disruption of the articulation between the radius and carpal bones. There are two groups: (group 1) it is either a pure radiocarpal dislocation or a minor avulsion of the radial styloid and (group 2) a fracture-dislocations characterized by a significant radial styloid fragment. Case Description The patient, a 66-year-old female involved in a car accident, underwent imaging studies and arthroscopic exploration, revealing a transcapitate perihamate translunate fracture-dislocation, associated with a radiocarpal dislocation type 1. Arthroscopic treatment was performed through common dorsal radiocarpal and midcarpal portals, along with the volar radial portal. Anatomical reduction of the joints and fractures was achieved under arthroscopic control, along with suturing of the volar radiocarpal ligaments. Literature Review The simultaneous occurrence of axial dislocation and radiocarpal dislocation, as observed in our case, is exceedingly rare and lacks comprehensive documentation in the existing literature. Furthermore, the specific type of axial dislocation (transcapitate perihamate translunate) has not been previously reported.Various treatment approaches, including closed reduction, open reduction, and external fixation, have been described for these types of complex pathologies, but few reports describe their arthroscopy management. Clinical Relevance This case report describes a rare occurrence of axial ulnar dislocation associated with radiocarpal dislocation of the wrist, which is exceptionally uncommon and not reported previously in the literature. This arthroscopic approach yielded excellent results, avoiding the need for multiple open approaches to address several fractures and ligament injuries.

Comparison of femoral tunnel position and knee function in anterior cruciate ligament reconstruction: a retrospective cohort study using measuring-fluoroscopy method versus bony marker method

BackgroundPrevious studies have shown that surgical technique errors especially the wrong bone tunnel position are the primary reason for the failure of anterior cruciate ligament (ACL) reconstruction. In this study, we aimed to compare the femoral tunnel position and impact on knee function during the ACL reconstruction using measuring combined with fluoroscopy method and bony marker method for femoral tunnel localization.MethodsA retrospective cohort study of patients undergoing ACL reconstruction using the bony marker method or measuring combined with fluoroscopy for femoral tunnel localization was conducted between January 2015 and January 2020. A second arthroscopic exploration was performed more than 1 year after surgery. Data regarding patient demographics, the femoral tunnel position, results of the Lysholm score, the International Knee Documentation Committee (IKDC) score, KT-1000 side-to-side difference, pivot shift grade, and Lachman grade of the knee were collected.ResultsA total of 119 patients were included in the final cohort. Of these, 42 cases were in the traditional method group, and 77 cases were in the measuring method group. The good tunnel position rate was 26.2% in the traditional method group and 81.8% in the measuring method group (p < 0.001). At the final follow-up, the Lysholm and IKDC scores were significantly greater in the measuring method group than the traditional method group (IKDC: 84.9 ± 8.4 vs. 79.6 ± 6.4, p = 0.0005; Lysholm: 88.8 ± 6.4 vs. 81.6 ± 6.4, p < 0.001). Lachman and pivot shift grades were significantly greater in the measuring method group (p = 0.01, p = 0008). The results of KT-1000 side-to-side differences were significantly better in the measuring method group compared with those in the traditional method group (p < 0.001).ConclusionsThe combination of the measuring method and intraoperative fluoroscopy resulted in a concentrated tunnel position on the femoral side, a high rate of functional success, improved knee stability, and a low risk of tunnel deviation. This approach is particularly suitable for surgeons new to ACL reconstructive surgery.

A modified partial wedge-shaped metaphyseal ulnar osteotomy for the treatment of ulnar impaction syndrome with reverse oblique sigmoid notch.

We describe a modified metaphyseal ulnar osteotomy to treat ulnar impaction syndrome with a reverse oblique sigmoid notch. Based on a computational analysis of radiographs, a modified wedge metaphyseal ulnar osteotomy was devised with its apex positioned at the ulnar styloid base to avoid impaction between the sigmoid notch and ulnar head. Subsequently, nine patients with ulnar impaction syndrome and a reverse oblique sigmoid notch underwent this operation, combined with arthroscopic exploration and transosseous triangular fibrocartilage complex repair. The mean follow-up was 14 months. All patients achieved bone union within 5 weeks, with no degenerative changes being observed during the follow-up assessments. The final follow-up assessments revealed decreases in ulnar variance and in the scores for Visual Analogue Scale, Quick Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Wrist Evaluation. All patients achieved excellent or good grades on the Modified Mayo Wrist Score. This technique is effective in treating the ulnar impaction syndrome with a reverse oblique sigmoid notch.Level of evidence: IV.

Evaluation of Canine Shoulder Arthroscopy for Anatomical and Safety Considerations.

Arthroscopy is a well-established diagnostic modality for various orthopaedic conditions in veterinary medicine. The aim of this study was to describe the relationship of canine shoulder arthroscopy portals to major muscular, ligamentous, and neurovascular structures for anatomical and safety considerations. Arthroscopic exploration of 20 adult canine cadaver shoulders was performed. Each shoulder region was dissected layer by layer to the level of the joint. Musculotendinous, ligamentous, and cartilaginous lesions were documented. The distance was measured from each portal to neurovascular structures encountered. Muscular lesions included the deltoideus, cleidobrachialis, omotransversarius, supraspinatus, infraspinatus, and teres minor muscles. The neurovascular structures identified were the omobrachial vein, the caudal circumflex humeral artery, axillobrachial vein, and branches of the axillary nerve. Lesions to the lateral glenohumeral ligament were noted from the caudal instrument portal and the middle arthroscope portal. Iatrogenic articular cartilage injuries were identified on the caudal humeral head and the glenoid. This study supports the safety of lateral shoulder arthroscopy in dogs. Most local neurovascular structures are unaffected with traditional scope portal positions. Musculotendinous lesions are unavoidable due to the extensive muscling surrounding the shoulder but are unlikely to cause severe complications postoperatively.

Analysis of the correlation between media meniscus displacement index and medial tibiofemoral articular cartilage damage

To investigate the correlation between the medial meniscal indentation index (MDI) and medial tibiofemoral articular cartilage damage more than 3 degrees in patients aged 40 to 60 years old with suspected or complicated knee osteoarthritis at non-weight-bearing position, and to determine the predictive threshold. From June 2016 to June 2020, a total of 308 patients who underwent initial knee arthroscopic exploration for chronic knee pain were collected. The age ranged from 36 to 71 years old with an average of(56.40±1.82) years old, including 105 males and 203 females. And patients with extra-articular malformations (abnormal force lines), a history of trauma, inflammatory arthritis and other specific arthritis were excluded. Finally, 89 eligible cases were obtained, aged from 42 to 60 years old with an average of (59.50±0.71) years old, including 45 males and 44 females. The degree of cartilage damage in the medial compartment of the knee joint was recorded, which was divided into two groups(≥degree 3 and<degree 3) according to Outer-Bridge classification system. The possible risk factors were determined by univariate analysis in the age, gender, affected sides, body mass index (BMI), synovial thickening grade, meniscus injury and MDI of 2 groups. Then, the independent risk factors for cartilage injury of more than grade 3 were determined by further binary Logistic regression analysis. If MDI was taken as an independent risk factor, receiver operating characteristic (ROC) analysis was performed to confirm whether it had diagnostic value for cartilage damage of above degree 3 and calculate the critical value of MDI. A total of 89 eligible patients were obtained. Univariate analysis showed age, BMI, MDI and meniscus injury may be the independent risk factors for cartilage damage of more than 3 degrees, further binary Logistic regression analysis confirmed that MDI[OR=1.66, 95%CI(1.64, 1.69), P=0.01]and BMI [OR=1.58, 95%CI(1.17, 2.15), P=0.03] were independent risk factors for cartilage injury of more than degree 3 in enrolled patients. ROC analysis showed that MDI had more diagnostic value than BMI, and the critical value was 0.355 with a sensitivity of 89.1% and a specificity of 88.2%. In doubt or accompanied by 40 to 60 years old patients with knee osteoarthritis, the MDI measured by non-weight-bearing knee MRI has predictive value for cartilage injury of more than degree 3 in medial tibiofemoral joint, and the critical value for diagnosis of cartilage injury of more than degree 3 is 0.355.

Arthroscopic treatment of deep gluteal syndrome and the application value of high-frequency ultrasound

PurposeThis study aimed to evaluate the efficacy of arthroscopic sciatic neurolysis for treating deep gluteal syndrome (DGS) and to analyse the application value of high-frequency ultrasound during perioperative period.MethodsBetween June 2020 and February 2022, 30 patients with DGS who underwent failed conservative treatment were retrospectively analysed. Lateral arthroscopic exploration of the deep gluteal space and sciatic neurolysis were performed. In addition to pelvic X-ray, lumbar disc and hip magnetic resonance imaging (MRI), ultrasonography of the sciatic nerve was also performed in all patients. The visual analogue scale pain score (VAS), modified Harris hip score (mHHS) and Benson symptom-rating scale were used to evaluate the clinical efficacy. The correlation between preoperative sciatic nerve ultrasound and arthroscopic findings was analysed.ResultsThe median follow-up for these patients was 13 months (range,12–21 months). Preoperative ultrasonography showed precise morphological changes in 26 sciatic nerves of patients. The VAS score decreased from 5.0 (4.0, 6.0) preoperatively to 0.5 (0, 1.0) postoperatively (p < 0.001), and the mHHS increased from 64.0 (57.0, 67.0) preoperatively to 95.0 (93.0, 97.0) postoperatively (p < 0.001). The Benson symptom score was excellent in 15 cases, good in 12 cases, fair in 2 cases, poor in 1 case; thus, the score was excellent or good in 90% of the cases. Preoperative ultrasound diagnosis and intra-operative findings matched up in all cases. There were four cases of transient numbness in the posterior thigh.ConclusionsArthroscopic sciatic neurolysis is a safe and effective treatment option for DGS patients who fail conservative treatment. Ultrasound diagnosis matched the arthroscopic findings perfectly. Preoperative Doppler ultrasound can assist surgical decision-making, guide intraoperative release.

Methods of analyzing the long head of the biceps tendon in the management of distal supraspinatus tendon ruptures. Part 2: The role and validation of an arthroscopic exploration protocol of the long head of the biceps tendon

IntroductionInter-observer arthroscopic assessments of the Long head of the Biceps tendon (LHB) injuries, in the absence of predefined instructions, are poorly reproducible. There are several types of LHB injuries, of varying severity, which can make its intraoperative analysis subjective. HypothesisThe application of a precise arthroscopic exploration protocol, particularly dynamic, associated with an equally precise analysis of the possible tendon lesions, intrinsic or extrinsic, makes it possible to obtain a reproducible analysis of the lesions of the LHB and aid decision-making around its conservation or its resection, in distal supraspinatus tendon ruptures. Material and methodsThis was a prospective, multicenter study including 371 patients with a stage 1 rupture of the supraspinatus tendon, in accordance with the Patte classification. An exploration protocol with intraoperative video recording of the articular portion of the biceps was systematically performed by the operators. It included static intra-articular and extra-articular observation of the LHB, as well as a dynamic intra-articular hook test with mobilization in internal and external rotation, and in anterior elevation. An analysis of the lesion status of the LHB was then made by the principal operator (Op), after defining the various possible lesions: intrinsic or extrinsic. This initial diagnostic assessment was then compared with the analysis made by two independent observers (Obs1, Obs2) based on a replay of the recorded videos. The reliability of agreement was then measured using Cohen's Kappa coefficient (K) and Fleiss’ kappa. ResultsTwo hundred and fifty-seven videos were analyzable. The level of agreement between the two independent observers was strong (K=0.63) for applying the diagnosis of a healthy or pathological biceps. The agreement between the independent observers and the operator was weaker (respectively K Op-Obs1=0.51 - moderate and K Op-Obs2=0.39 - poor). ConclusionThe application of a precise protocol for the exploration of the LHB, associated with a previously defined lesion classification, makes it possible to obtain a high rate of agreement for the arthroscopic diagnostic analysis of the LHB. However, arthroscopy cannot be used as the only criterion for deciding which procedure to perform on the LHB. Other clinical and para-clinical factors must be taken into consideration. Level of evidenceIII; prospective inter-observer series.

Influence of a posteromedial meniscocapsular injury on the knee anterior laxity. A cadaveric study.

The number of anterior cruciate ligament (ACL) injuries has considerably increased in the recent years, especially in young adults and adolescents. Associated meniscal tears increase anterior and rotary laxity. Posterior peripheral meniscocapsular tear of medial meniscus is also called ramp lesion. Prevalence of 9% to 17% in adults and up to 23% in pediatric population has been reported. The aim of this study was to determine anterior laxity of cadaveric ACL-deficient knees with several size of ramp lesions. Fresh cadaveric knees were explored. Major osteoarthritis and/or ACL and meniscal tears on arthroscopy were exclusion criteria. Mean age at death was 86years old. Dynamic laximetry with GNRB® device was made in several conditions: Knee prior to any procedure, after arthroscopic exploration, after ACL section, and then after increasing sizes of ramp lesions up to 30mm. Anteroposterior laxity was measured with 2 loading forces successively (134N and 200N). After ACL section only, tibiofemoral joint anterior laxity was significantly increased. Mean increase was 156% regardless of the loading force. No statistical laxity difference was found between knees with ACL section only and knees with ACL and meniscal section for any size of ramp lesions. Increasing size of ramp lesion was not correlated with increasing of laxity. We could not find a threshold size of ramp lesion which increases knee anterior laxity. We were not able to determine a threshold recommending a ramp lesion repair.

Dry Wrist Arthroscopy: Technique and Rationale

Wrist arthroscopy has been established as a useful, minimally invasive tool for diagnosing and treating many different wrist conditions. The standard portals are located on the dorsum of the hand and wrist and are named for their relation to the extensor compartments. They include the radiocarpal and midcarpal portals. The radiocarpal portals are 3-4, 4-5, 6R, 6U, and 1-2. The midcarpal portals are STT (scaphotrapeziotrapezoidal), MCR (midcarpal radial), and MCU (midcarpal ulnar). Traditionally, wrist arthroscopy is performed with constant inflow of saline solution for joint insufflation and visualization. Dry wrist arthroscopy (DWA) is a technique that allows for arthroscopic exploration and instrumentation without infusing any fluid into the joints. Some advantages of DWA include lack of fluid extravasation, less obstruction by floating synovial villi, decreased risk of compartment syndrome, and the ability to perform concomitant open procedures more easily than with a wet technique. Additionally, the risk of fluid displacing carefully laid bone graft is much less without constant flow. DWA can be used in the assessment and management of triangular fibrocartilage complex (TFCC) and scapholunate interosseous ligament tears and other ligamentous injuries. DWA can also be used in fracture fixation to assist with reduction and restoration of articular surfaces. Moreover, it is used in more chronic settings to diagnose scaphoid nonunions. DWA does have its disadvantages such as generation of heat through the use of burrs and shavers and clogging of these instruments during debridement of tissue. DWA is a technique that can be used to manage multiple orthopaedic conditions including soft-tissue and osseous injuries. With a minimal learning curve for surgeons who already perform wrist arthroscopy, DWA can be a useful addition to their practice.

Arthroscopic popliteal tenotomy grants satisfactory outcomes in total knee arthroplasty with persistent localised posterolateral pain and popliteus tendon impingement.

The purpose was to estimate the prevalence of popliteus tendon impingement following TKA, and to describe the characteristics and the differential diagnosis protocol for this rare condition. The hypothesis was that arthroscopic popliteal tenotomy in TKA patients with suspected popliteus tendon impingement would relieve pain and improve satisfaction. Of 741 TKAs performed over three years, eight (1.1%, all women) had suspected popliteus tendon impingement, of which seven had severe localised posterolateral knee pain and one global knee pain. Upon confirmation of popliteus tendon impingement, arthroscopic popliteal tenotomy was performed, and outcomes (Pain on visual analogue scale (pVAS; best, 0; worst, 10), Oxford Knee Score (OKS; best, 48; worst, 0) and satisfaction (best, 100%; worst, 0%) assessed at mean 18-month follow-up. At four to 30months after TKA, arthroscopic exploration revealed popliteus tendon impingement in all eight knees. Six reported complete pain relief (pVAS, 0) the day following arthroscopic popliteal tenotomy, whilst one reported some residual pain (pVAS, 2). The remaining patient with global pain reported no pain relief, and required revision TKA at 12months. Excluding the revised TKA, OKS was between 19 and 43, and satisfaction was rated ≥ 80% in five of the remaining seven patients. Arthroscopic popliteal tenotomy relieved symptoms in TKA patients with persistentlocalised posterolateral pain and a positive popliteus test. These findings suggest that the popliteus test is reliable to diagnose popliteus tendon impingement following TKA, which could be treated by arthroscopic popliteal tenotomy. Level IV, Small case series.

Comparison of dorsal and medial arthroscopic approach to canine coxofemoral joint: a cadaveric study

Arthroscopic exploration of ventromedial part of canine coxofemoral joint is limited in conventional dorsal approach. We evaluated the efficacy of a medial arthroscopic approach to the coxofemoral joint of dogs by analyzing the joint visible area and performing a safety analysis. Arthroscopic approaches to the coxofemoral joint were made in five cadavers using a traditional (dorsal) and novel (medial) approach. Three observers scored the visible area of images and videos of the acetabulum and femur. A safety analysis was performed via dissection of the medial hind limb. The distance between neurovascular structures and arthroscopic portals was measured. The acetabulum was more visible in the dorsal than in the medial approach, with mean visualization scores of 16 ± 0.00 and 11.83 ± 1.26, respectively. The medioventral side of the femur was significantly more visible in the medial than in the dorsal approach, with mean visualization scores of 3.9 ± 0.99 and 6.93 ± 0.58, respectively. Safety analysis confirmed the medial portal site was safe, provided that the surgeon has comprehensive knowledge of the joint. The minimum distance from the arthroscopic medial portals to the nearest neurovascular structures was 2.5 mm. A medial arthroscopic approach to the canine coxofemoral joint has potential clinical application. Dorsal and medial approaches differ significantly and have distinct purposes. The medial approach is useful to access the ventromedial joint, making it an eligible diagnostic method for an arthroscopic evaluation of this area.

Synovial chondromatosis of knee joint: a case report

&lt;p class="abstract"&gt;Synovial chondromatosis is a benign condition encountered infrequently within joints which is also known as synovial osteochondromatosis. They present as multiple nodules in the synovium which are either fibrin type or cartilaginous type. The fibrin type usually results from bleeding within the joint, rheumatoid arthritis and tuberculosis. The cartilaginous type is usually due to trauma or osteoarthritis. This typically involves large joints, knee being the most common, rarely small joints also may be involved. Here we report a case of 30-year-old female who presented to us with symptoms of swelling, restriction of movement and pain in the right knee. After clinical and radiological assessment, arthroscopic exploration with loose body removal and synovectomy done, following which patient achieved painless complete range of movements. Histopathological examination confirmed the diagnosis as synovial chondromatosis.&lt;/p&gt;

Short-term effectiveness of high tibial osteotomy combined with arthroscopic surgery for knee varus arthritis and the results of secondary arthroscopic exploration

To investigate the effectiveness of high tibial osteotomy (HTO) combined with arthroscopic surgery to treat medial compartment knee osteoarthritis (KOA) and secondary arthroscopic exploration to evaluate the outcome of cartilage and meniscus. A clinical data of 57 patients with medial compartment KOA with varus deformity of lower extremities admitted between August 2014 and October 2018 were retrospectively analyzed. There were 23 males and 34 females with an average age of 51.2 years (range, 41-63 years). The disease duration ranged from 2 to 8 years, with an average of 4.7 years. The preoperative femorotibial angle was (179.86±4.69)°, the relative position of the lower limb mechanical axis passing through the tibial plateau was 24.21%±6.98%, and the posterior slope of the tibial plateau was (5.23±1.45)°. The Kellgren-Lawrence grade of knee joint was grade Ⅱ in 22 cases and grade Ⅲ in 35 cases. The preoperative Hospital for Special Surgery (HSS) score, Lysholm score, and visual analogue scale (VAS) score were 59.1±7.3, 48.8±7.6, and 6.2±1.1, respectively. Arthroscopic exploration was performed during the operation to record the articular cartilage degeneration in the weight-bearing area of the medial compartment (Outerbridge grade Ⅰ in 18 cases, grade Ⅱ in 30 cases, and grade Ⅲ in 9 cases) and the condition of the medial meniscus injury, and the corresponding treatment was performed. The coronal force line was adjusted according to the preoperative Kellgren-Lawrence grade of the knee joint during the operation. After operation, the relative position of the lower limb mechanical axis passing through the tibial plateau, the femorotibial angle, and the posterior slope of the tibial plateau were measured; the Kellgren-Lawrence grade of the knee joint was recorded; the Outerbridge grade of articular cartilage degeneration and the meniscus outcome were evaluated by combining with the MRI of the knee joint at 1 year after operation and the second arthroscopic exploration when the internal fixator was removed. The function and pain of the knee were evaluated by Lysholm score, HSS score, and VAS score. All the 57 patients were followed up 36-58 months with an average of 42.1 months. Incisions healed by first intention, and no neurovascular injury, intraarticular or hinge fractures occurred during operation, and no postoperative complications such as deep vein thrombosis of lower limbs and internal fixation failure occurred. All the osteotomy sites healed at 3 months after operation. At 1 year after operation, the internal fixator was removed, and the second arthroscopic exploration showed that there were 15 cases of Outerbridge grade Ⅰ, 31 cases of grade Ⅱ, and 11 cases of grade Ⅲ in the weight-bearing area of the medial compartment, and there was no significant difference when compared with preoperative grade ( Z=31.992, P=0.997); there was no cartilage degeneration in other compartments. Meniscus healing was seen in the injured meniscus, and no injury was seen in the normal meniscus. At last follow-up, there were 19 cases of Kellgren-Lawrence grade Ⅱ and 38 cases of grade Ⅲ, and there was no significant difference when compared with preoperative grade ( Z=49.049, P=0.764). The relative position of the lower limb mechanical axis passing through the tibial plateau was 59.16%±2.87%, and the femorotibial angle was (171.54±3.39)°, which significantly improved when compared with those before operation ( P<0.001). The posterior slope of the tibial plateau was (5.65±1.22)°, which was not significantly different from that before operation ( t=-1.673, P=0.096). The HSS score, Lysholm score, and VAS score were 82.3±7.7, 83.4±6.4, and 1.6±1.1 respectively, which were significantly different from those before operation ( P<0.001). HTO combined with arthroscopic surgery for medial compartment KOA with varus deformity of lower extremities can effectively improve the force line of lower extremities, relieve pain symptoms, and improve joint function, with satisfactory short-term effectiveness, and without significant progress in articular cartilage or meniscus injury after operation.

Needle arthroscopy for exploration of the elbow joint: a case series of six dogs with preliminary cadaveric study

Case history: Dogs (n = 6) suffering from elbow-associated lameness for a median of 3.5 (min 2, max 12) months duration requiring arthroscopic exploration according to imaging results were prospectively included in this study. Clinical findings: Dogs that met the inclusion criteria were of various breeds with a median body weight of 18 (min 13.2, max 34.5) kg and median age at presentation of 11 (min 6, max 96) months. Results of imaging modalities (radiographs and/or CT) were consistent with developmental elbow disease in all of the dogs. Arthroscopic findings: Feasibility of the needle arthroscopy procedure was first assessed in a preliminary cadaveric study. Disease-free cadaveric forelimbs (n = 12) were collected from adult dogs (n = 6) euthanised for reasons unrelated to the present study. Elbow exploration was performed, beginning with needle arthroscopy (1 mm, 0° angle scope) followed by standard arthroscopy (2.4 mm, 30° angle scope) through a medial approach. The ease of introduction, range of motion and the quality of visualisation were assessed subjectively and presence of iatrogenic introduction lesions and extent of field of vision (assessed by the number of anatomical structures visualised) were scored and statistically compared. Needle arthroscopy allowed inspection of all structures at risk for medial/caudal compartment disease in all joints considering the occasional need for multiple portals. In the clinical setting, elbow exploration was found to be similar to that in cadaver joints in 4/6 dogs. The lower quality of vision provided by needle arthroscopy was a limitation of the technique, and 2/6 clinical cases required conversion to standard arthroscopy for full visualisation of the joint. No introduction lesions were noted with needle arthroscopy in either the cadaveric or clinical studies. Conclusions and clinical relevance: Needle arthroscopy allowed safe visualisation of all the structures of the medial and caudal compartment in disease-free cadaveric elbows, suggesting that needle arthroscopy is an appropriate technique for diagnosis and assessment of lesions of developmental elbow disease. However, the low quality of vision provided by the 1 mm scope, and the small diameter of the sleeve, which limited fluid inflow, combined with fragility of the device were major drawbacks that prevented consistent full exploration of the joint and detailed lesion assessment in clinical situations. Improvement of the device is thus necessary before use of the technique in clinical practice can be recommended.

Medial compartment cartilage repair and lower extremity biomechanical changes after single-plane high tibial osteotomy of distal tibial tuberosity

ObjectiveTo observe the cartilage repair of the medial compartment and the biomechanical changes of the lower extremities after single-plane high tibial osteotomy of distal tibial tuberosity (DTT-HTO). MethodsA total of 30 patients, including 11 males and 19 females, who underwent DTT-HTO with arthroscopic operation in our hospital from January 2020 to January 2021 and underwent arthroscopic exploration again during the second operation for internal fixation were enrolled. There were 32 knees, including 13 left knees and 19 right knees. Age ranged from 50 to 78, with an average of 63.20 ± 6.61 years old. All patients completed two surgeries and were followed up, and no adverse events occurred during the period. International Cartilage Repair Society (ICRS) was used to assess the cartilage condition of the medial compartment of the knee during the two surgeries. In this paper, the weight-bearing line ratio (WBLR), the medial proximal tibia angle (MPTA), the femoral tibial angle (FTA) and the posterior tibial slope (PTS) were used to evaluate the changes of the mechanical state of the lower limbs. The visual analogue scale (VAS) score and the Western Ontario and McMaster University Osteoarthritis (WOMAC) Index score were used to evaluate the improvement in knee pain and function. ResultsAll patients completed two operations without adverse events and serious complications. The medial compartment cartilage of all patients had different degrees of repair during the second operation, and the difference was statistically significant compared with the first operation (P < 0.05). During the second operation, the WBLR was corrected from (17.69 ± 2.16)% to (60.90 ± 1.97)%, the MPTA was corrected from (80.72 ± 1.61)° to (89.91 ± 2.58)°, the FTA was corrected from (182.31 ± 3.03)° to (171.81 ± 2.24)°, the difference was statistically significant (P < 0.05). There was no statistical difference in PTS between the two surgeries (P > 0.05). At the second operation, the VAS score decreased from 7.50 ± 1.34 to 0.34 ± 0.85, the WOMAC score decreased from 119.50 ± 10.43 to 46.25 ± 4.13, and the difference was statistically significant (P < 0.05). ConclusionDTT-HTO can significantly correct the weight-bearing line, restore the biomechanical parameters of the lower limb to the normal range, significantly relieve pain and improve knee function, and the medial compartment cartilage repair and regeneration phenomenon will occur after the correction of the weight-bearing line.

Arthroscopic Synovectomy for Tenosynovial Giant Cell Tumor/Pigmented Villonodular Synovitis in the Posterior Knee Using the Posterior Trans-Septal Portal Technique.

The patient is positioned such that the contralateral leg will not obstruct the ability to work in the posteromedial portal. Diagnostic arthroscopy is performed through standard anteromedial and anterolateral portals. Next, with visualization from the anterolateral portal and the knee in 90° of flexion, the posteromedial portal is created with use of a transilluminated spinal needle. The posterolateral portal is made in the same fashion as the posteromedial portal, with use of a trans-notch view from the anteromedial portal. With the arthroscope in the posteromedial portal, a blunt instrument or motorized shaver can be placed through the posterolateral portal to perforate the posterior septum and create the TSP. The mass can then be identified, biopsied, and removed with use of a motorized shaver or tissue grasper. Arthroscopic exploration through the TSP can then be done to confirm adequate excision. Alternatives include synovectomy either by arthrotomy, arthroscopy via a posteromedial or posterolateral portal with trans-notch views, or a combination of both. To limit the risk of recurrent diffuse PVNS, radiosynovectomy with yttrium-90 or phosphorus-32, either combined with surgery or alone, has been described2,17. External beam radiation has also been utilized, but radiation toxicity is seen as a major limitation17. Macrophage-colony stimulating factor (M-CSF) or CSF-1 inhibitors have recently been developed. In 2019, the FDA approved the use of CSF-1 inhibitors, and they are considered an acceptable treatment for patients who are not candidates for surgical resection17. Advantages involve increased posterior anatomy visualization to ensure adequate synovectomy, more working capacity for instruments, and decreased disruption of anatomical planes and scar tissue formation around neurovascular structures compared with open dissection10-16. Excellent clinical results (defined by return to full knee function) have been reported for the TSP technique for PVNS synovectomy. In a study of 10 cases of posterior-knee PVNS masses removed via arthroscopic synovectomy with use of a TSP, Shekhar et al. reported good functional outcomes and no operative complications2. Keyhani et al. reported a series of 21 patients who underwent the same procedure for diffuse PVNS with similar findings9. Patients can expect to retain close to full knee function following this procedure2,9. Baseline magnetic resonance imaging is recommended for all patients at 3 to 6 months after excision, as asymptomatic recurrence can occur, and patients should be followed for a minimum of 2 years post-excision2,3,7,9,18. Keeping the knee in 90° of flexion provides the furthest distance from the saphenous vein on the medial side, the peroneal nerve on the lateral side, and the popliteal artery near the posterior septum when making the posterior portals10-16.Transillumination of the posterior portals is recommended10-16.Perforation of the septum should be in the posterolateral to posteromedial direction, allowing surgeons to have a wider "safe zone" to decrease the chance of vascular injury to the popliteal artery14. CSF = colony-stimulating factorMCL = medial collateral ligamentMRI = magnetic resonance imagingPL = posterolateralPM = posteromedialPA = popliteal arteryROM = range of motionTS = trans-septalIKDC = International Knee Documentation Committee.

Arthroscopic Management of Synovial Chondromatosis of the Knee Joint

Synovial Chondromatosis is a rare and it is a benign condition characterized by multiple cartilaginous nodules in synovial facet spaces. Synovial Chondromatosis affects most commonly the knee joint. This is a case report of a 30-year-old male patient presented with pain and swelling over the left knee joint. On evaluation MRI shows loose bodies, for which he underwent, arthroscopic exploration. Viscous fluid and loose bodies were identified and showed synovial hyperemia. Synovial debridement was done and loose bodies were removed and sent to histopathological examination. The result signify that arthroscopy is efficient method both in diagnostic as well as therapeutic management of synovial chondromatosis.

Diagnosis of medial meniscal ramp lesion is difficult by pre-operative magnetic resonance imaging evaluation and needs a methodical arthroscopic exploration

BackgroundMeniscal ramp lesion (RL) is the peripheral lesion of the posterior horn of the medial meniscus (PHMM) associated with anterior cruciate ligament (ACL) tear. The purpose of this study was to evaluate the accuracy of pre-operative magnetic resonance imaging (MRI) evaluation in diagnosing RL and to identify whether the difficulty in diagnosis differs depending on the location of RL. MethodsACL-injured patients undergoing ACL reconstruction from January 2017 to January 2019 were enrolled. A methodical arthroscopic exploration to identify RL was conducted intra-operatively using three steps, namely, the anterior visualization step, the inter-condylar visualization step, and the posteromedial step. The location of the RLs was evaluated and classified into two types as follows: Red-red zone (RR) - a meniscal tear of the red-red zone of the PHMM. Menisco-capsular junction (MCJ) - a lesion at the menisco-capsular junction of the PHMM, which is more peripheral than RR. Furthermore, the accuracy of 1.5-T MRI evaluation to diagnose RL by two testers using sagittal proton-density fat-saturated images was calculated. ResultsOf the 81 patients enrolled, 11 had RL: 5 cases each were at the MCJ and RR, and 1 case was at both locations. The sensitivity of MRI for detecting RL was 27.3–45.5%, whereas the specificity was 84.3–95.7% in total. The sensitivity of MRI in detecting RL at the RR and MCJ was 40.0–80.0%, 0–20.0%, respectively. The intra-observer reliability of the MRI evaluation was moderate (κ coefficient: 0.40–0.46), while the inter-observer reliability was fair to moderate (κ coefficient: 0.27–0.41). ConclusionsA low sensitivity of the MRI in detecting RL at the MCJ was observed, and the reliability of the MRI evaluation for diagnosis of RL was not high. Therefore, methodical arthroscopic exploration is essential to diagnose RL even when it is not suspected on pre-operative MRI.

Intra-articular fibrous bands at the tibiotalar joint: diagnosis and outcomes of arthroscopic removal in 4 ankles

The authors retrieved the records of 4 patients that exhibited unusual structural anomalies or pathologies, notably the presence of a fibrous band at the anterior aspect of the tibiotalar joint, observed during arthroscopic exploration or treatment between January and December 2019. Only 1 patient had surgical antecedents on the ipsilateral ankle (extra-articular tenodesis 10 years earlier). The remaining 3 patients had no surgical antecedents on the ipsilateral ankle. The fibrous band was removed in all patients during arthroscopic Brostöm procedure or exploration. For the first 3 patients, the intra-articular fibrous band was not observed prior to arthroscopy by either the senior surgeon or radiologist on any of the images (2 MRIs and 1 CTA), but retrospective inspection confirmed that the intra-articular fibrous band was present but had been overlooked.At a follow-up of 22.3 ± 5.0 months (range, 15–26), all patients reported a decrease in pVAS (− 5.0 ± 2.6, range, 2–8), and an improvement in AOFAS (51.0 ± 17.7, range, 26–65), EFAS (14.5 ± 8.7, range, 6–23) and EFAS sport (8.0 ± 5.3, range, 2–10).This case report corroborates the findings of an earlier discovery of an intra-articular fibrous band in 4 ankles, with more detailed information for clinical and radiologic diagnosis, as well as outcomes of arthroscopic removal. Clinicians should beware of such foreign bodies in the ankle, particularly in patients with history of sprains, and consider arthroscopic removal in cases with persistent pain and/or functional impairment.

Superior Capsular Reconstruction of the Shoulder

For irreparable rotator cuff tears, superior capsular reconstruction (SCR) has become an option for restoring glenohumeral joint stability and reversing proximal humeral migration. Signs of irreparable rotator cuff tears include pain from subacromial impingement, muscle weakness, and pseudoparalysis. In biomechanical studies, Mihata etal. showed SCR with fascia lata graft and side-to-side suturing to remaining infraspinatus tendon restored superior stability of the shoulder joint. Adding acromioplasty decreased the subacromial contact area without altering the humeral head position, superior translation, or subacromial peak contact pressure. The same research group showed that using an 8-mm thick fascia lata graft attached at 15° to 45° of shoulder abduction optimized superior stability of the shoulder joint. Adams etal. performed SCR using a dermal allograft and found that greater glenohumeral abduction angle (60°) decreased applied deltoid force. SCR can be performed with the patient in the lateral decubitus or beach chair position. Arthroscopic exploration, debridement, and infraspinatus and supraspinatus repair attempt is completed before proceeding with SCR. To restore the superior capsule of the shoulder, the graft (fascia lata autograft, dermal allograft) can be attached to the superior glenoid medially and the rotator cuff footprint on the greater tuberosity of the humerus laterally, after debriding bone to enhance healing. SCR with side-to-side suturing to the remnant rotator cuff yields promising clinical results. Using a fascia lata autograft, Mihata etal. showed a reversal of pseudoparalysis in 93% to 96% of patients and mean active elevation, external rotation, and acromiohumeral distance on radiography all improved. Using a dermal allograft and a unique graft delivery technique, Burkhart etal. reversed pseudoparalysis in 9 of 10 patients and 70% of patients had completely intact grafts. Recommendations for rehabilitation and return to activity vary, but adequate time for graft healing is recommended.