Diagnostic Knee Research Articles

Is Partial ACL Tear a Cause of Painful Swollen Knees?

Abstract Study Design: Retrospective case series. Objective: In this study, we will identify if partial ACL tear is a common hidden cause of chronic pain and swelling of the knee in adults. And we will evaluate the effectiveness of arthroscopic selective bundle reconstruction in the management of this condition. Background: The Anterior Cruciate Ligament (ACL) has two anatomical bundles, the anteromedial (AM) and the posterolateral (PL), each bundle was named according to the site of its tibial insertion.[1] Partial ACL tear is evident and symptomatic when the percentage of the torn fibers is more than 50% of ligament fibers. AM bundle is more liable to injury than PL.[2] Symptomps of partial ACL tear may be giving way and instability but persistent knee pain and swelling is often present as the main presenting symptom of the patient due to micro-instability of the knee, The primary complication of longstanding partial ACL tears is early knee degeneration.[3] Patients and Methods: 37 patients with chronic knee pain and swelling, related to activity and resistant to non-operative treatment, underwent diagnostic knee arthroscopy. In 3 cases diagnostic arthroscopy revealed osteochondral ulcers of the medial compartment of the knee managed by drilling and 4 cases showed non-specific synovitis managed by arthroscopic synovectomy. 30 of these patients, who were included in this study, were found to suffer from partial ACL tear and underwent single bundle reconstruction, 18 of them underwent selective AM bundle reconstruction while preserving PL bundle. Twelve patients underwent selective PL bundle reconstruction with AM bundle preservation. Semitendinosus tendon graft was utilized for all reconstructions. The femoral side was always fixed with an adjustable loop (Zimmer), and the tibial side with a biodegradable interference screw. Lysholm score[4] was used to assess the outcomes. Patients with severe degenerative disorders, lower limb mal-alignment and multiple ligamentous injuries of the knee were excluded from our study. Results: Marked decrease in the knee pain and swelling postoperatively. The preoperative score had a mean value of 66.17±10.39. At 2 years, the postoperative score was 96.1±6.71, indicating a highly statistically significant improvement (P value 0.001). Hypothesis: Partial ACL tears are the commonest hidden cause of pain and swelling of the knee among young adults. Conclusion: Arthroscopic selective bundle reconstruction diminishes knee pain and swelling with a very satisfactory postoperative clinical outcomes.

Comparison of needle and conventional arthroscopy for visualisation of predefined anatomical structures of the knee joint: a feasibility study in human cadavers and patients

BackgroundIn terms of the optics used for Knee arthroscopy, a large number of different endoscopes are currently available. However, the use of the 30° optics in knee arthroscopy has been established as the standard procedure for many years. As early as the 1990s, needle arthroscopy was occasionally used as a diagnostic tool. In addition to the development of conventional optics technology in terms of camera and resolution, needle arthroscopes are now available with chip-on-tip image sensor technology. To date, no study has compared the performance of this kind of needle arthroscopy versus standard arthroscopy in the clinical setting in terms of the visibility of anatomical landmarks.In this monocentric prospective feasibility study, our aim was to evaluate predefined anatomical landmarks of the knee joint using needle arthroscopy (0° optics) and conventional knee arthroscopy (30° optics) and compare their performance during knee surgery.MethodsExaminations were performed on eight cadavers and seven patients who required elective knee arthroscopy. Two surgeons independently performed the examinations on these 15 knee joints, so that we were able to compare a total of 30 examinations. The focus was on the anatomical landmarks that could be visualized during a conventional diagnostic knee arthroscopy procedure. The quality of visibility was evaluated using a questionnaire.ResultsIn summary, the average visibility for all the anatomic landmarks was rated 4.98/ 5 for the arthroscopy using 30° optics. For needle arthroscopy, an average score of 4.89/ 5 was obtained. Comparatively, the needle arthroscope showed slightly limited visibility of the retropatellar gliding surface in eight (4.5/ 5 vs. 5/ 5), medial rim of the patella in four (4.85/ 5 vs. 5/ 5), and suprapatellar recess in four (4.83/ 5 vs. 5/ 5) cases. Needle arthroscopy was slightly better at visualizing the posterior horn of the medial meniscus in four knee joints (4.9/ 5 vs. 4.85/ 5).ConclusionNeedle arthroscopy is a promising technology with advantages in terms of minimally invasive access and good visibility of anatomical landmarks. However, it also highlights some limitations, particularly in cases with challenging anatomy or the need for a wide field of view.

Arthroscopic Evaluation of Association of Meniscus Injuries in Patients with Anterior Cruciate Ligament Injuries

Background: The knee joint's stability relies significantly on the integrity of the meniscus and the anterior cruciate ligament (ACL). Chronic ACL tears can compromise knee stability, making the meniscus a crucial stabilizer. Understanding the prevalence and patterns of meniscus injuries associated with chronic ACL tears is essential for effective management. Objective: This study aimed to assess the arthroscopic evaluation of association of meniscus injuries in patients with anterior cruciate ligament injuries. Method: A retrospective analysis was conducted on thirty-three patients diagnosed with ACL injuries at MuMCH between January 2021 and December 2023. Patients aged 18-50 with ACL injuries, with or without meniscus damage, were included. Clinical evaluations, knee MRI scans, and diagnostic knee arthroscopies were performed. The study evaluated meniscus injuries associated with chronic ACL injuries and assessed outcomes using the modified Lysholm score. Results: The study revealed a predominant occurrence of meniscus injuries (70%) among participants, with a majority falling within the 38-47 years age bracket (45.45%) and a male majority (60%). Sports and accidental injuries accounted for 40% each, while road traffic accidents contributed 20%. Lateral meniscus tears were the most prevalent (30.30%), followed by combined medial and lateral meniscus tears (33.33%). Posterior horn tears were predominant, particularly in the medial meniscus. Conclusion: The study highlights a high incidence of meniscus injuries associated with chronic ACL tears, with medial meniscus injuries prevailing over lateral tears. Posterior horn tears were predominant, emphasizing the medial meniscus's significant role in knee stability. These findings underscore the importance of early detection and appropriate management of meniscus injuries in chronic ACL-deficient knees to prevent degenerative changes and optimize patient outcomes.

A Rare Cause of Recurrent Pain in Athletes: Synovial Hemangioma

Background: Synovial hemangioma is a rare neoplastic lesion, which can result in recurrent hemarthrosis and pain. It can affect any joint, tendon, or bursa, withal those around the knee. The intra-articular lesion is more prevalent and is more frequently diagnosed in female children or young adults. Indications: Surgery is indicated when patients present with recurrent painful hemarthrosis that affect daily living and functionality. Technique Description: Diagnostic knee arthroscopy, initially without tourniquet inflation, was performed to detect and study the extent of the lesion. Afterwards, the tourniquet was inflated to proceed with the surgical excision. Medial parapatellar approach was performed, and limits of the hemangioma were identified. Wide resection was performed taking care to not damage the medial meniscus and medial condyle cartilage. Neoplastic lesion was sent to pathology analysis. The tourniquet was deflated and hemostasis checked because these lesions can present extensive bleeding. Results: Localized, well-circumscribed, and encapsulated lesions have been reported to usually present low recurrence rate when completely excised. Discussion/Conclusion: It is a rare disease, and around 200 cases have been reported; therefore, conclusions about treatment and outcomes rely mostly on case series and case reports. Early diagnosis and treatment are paramount to prevent degenerative changes secondary to recurrent hemarthrosis. Patient Consent Disclosure Statement: 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.

Low Risk of Acute Iatrogenic Periprosthetic Joint Infection After Prosthetic Joint Aspiration

BackgroundSynovial fluid analysis is an essential tool in diagnosing periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). However, concern exists that aspiration may introduce infection into a noninfected joint. Therefore, the purpose of this study was to evaluate the incidence of iatrogenic PJI following diagnostic knee aspiration done within 6 months of the primary TKA. MethodsBetween 2017 and 2021, the senior surgeon performed over 4,000 primary TKAs and aspirated 155 knees in 137 patients for whom there was a suspicion for PJI within 6 months of their primary TKA. There were 22 knees diagnosed as infected from the initial aspiration and therefore were excluded from the study. The remaining 133 aspirates in 115 patients who were negative for infection were followed for 6 months for signs and symptoms of PJI to elucidate whether aspiration introduced infection into an initially noninfected joint. ResultsThere were 70 of 133 knees (52.6%) aspirated between 0 and 6 weeks after index TKA, 40 of 133 (30.1%) between 6 weeks and 3 months, and 23 of 133 (17.3%) between 3 and 6 months. At final follow-up, none of the 133 initially noninfected knees exhibited evidence of subsequent iatrogenic PJI or had subsequent surgery for infection. ConclusionWhile joint aspiration is a procedure with inherent risks, this study shows that the rate of iatrogenic PJI is extremely low (0%). Therefore, if infection is suspected, the surgeon should consider joint aspiration, even in the initial postoperative period, as the risk for introducing infection is far outweighed by the risk of missing an infection.

No difference in patient reported outcomes between cohorts undergoing lesion-specific surgery for osteochondritis dissecans of the knee

IntroductionThere is a paucity of data on patient reported outcome measures (PROMs) associated with surgical treatment of osteochondritis dissecans (OCD). As a result, preoperative patient and family counseling regarding expected outcomes is difficult. The purpose of this study was to compare pre-to post-operative changes in PROMs amongst cohorts of patients with OCD that underwent one of three lesion-specific surgical treatments: 1) transarticular drilling for stable lesions, 2) drilling and fixation for unstable lesions 3) grafting for unsalvageable lesions. MethodsThe electronic medical records of pediatric and adolescent patients with knee OCD, at a single institution between January 2017 and August 2019, were reviewed. Patients were categorized into one of three surgical groups, with initial determination confirmed at the time of surgery during diagnostic knee arthroscopy. Differences between groups were assessed with one-way analysis of variance (ANOVA). ResultsOf the 78 patients included in this study, 49 (62.8%) were male with a mean age of 13.5 ± 2.2 years. There was no significant difference between the surgical groups for baseline HSS Pedi-FABS (P = 0.58) or PROMIS Mobility (P = 0.47). There were no significant differences in PROMIS PI scores at baseline (P = 0.32), at latest follow-up (P = 0.72), or in interval change from baseline to follow-up (P = 0.42), between the three surgical groups. ConclusionLesion-specific surgical management of OCD led to similar improvements in PROMIS PI at a minimum of one-year follow-up. These results may better allow surgeons to reassure patients and families that outcomes are similar when lesions are treated through a lesion-specific algorithm. Level of evidenceLevel IV: Retrospective cohort study.

Virtual reality simulation training improve diagnostic knee arthroscopy and meniscectomy skills: a prospective transfer validity study

PurposeLimited data exist on the actual transfer of skills learned using a virtual reality (VR) simulator for arthroscopy training because studies mainly focused on VR performance improvement and not on transfer to real word (transfer validity). The purpose of this single-blinded, controlled trial was to objectively investigate transfer validity in the context of initial knee arthroscopy training.MethodsFor this study, 36 junior resident orthopaedic surgeons (postgraduate year one and year two) without prior experience in arthroscopic surgery were enrolled to receive standard knee arthroscopy surgery training (NON-VR group) or standard training plus training on a hybrid virtual reality knee arthroscopy simulator (1 h/month) (VR group). At inclusion, all participants completed a questionnaire on their current arthroscopic technical skills. After 6 months of training, both groups performed three exercises that were evaluated independently by two blinded trainers: i) arthroscopic partial meniscectomy on a bench-top knee simulator; ii) supervised diagnostic knee arthroscopy on a cadaveric knee; and iii) supervised knee partial meniscectomy on a cadaveric knee. Training level was determined with the Arthroscopic Surgical Skill Evaluation Tool (ASSET) score.ResultsOverall, performance (ASSET scores) was better in the VR group than NON-VR group (difference in the global scores: p < 0.001, in bench-top meniscectomy scores: p = 0.03, in diagnostic knee arthroscopy on a cadaveric knee scores: p = 0.04, and in partial meniscectomy on a cadaveric knee scores: p = 0.02). Subgroup analysis by postgraduate year showed that the year-one NON-VR subgroup performed worse than the other subgroups, regardless of the exercise.ConclusionThis study showed the transferability of the technical skills acquired by novice residents on a hybrid virtual reality simulator to the bench-top and cadaveric models. Surgical skill acquired with a VR arthroscopy surgical simulator might safely improve arthroscopy competences in the operating room, also helping to standardise resident training and follow their progress.Level of evidence2

Arthroscopic Meniscus Trephination: A Novel Technique for the Treatment of Symptomatic Meniscal Degeneration: Surgical Technique and Literature Review.

Meniscal pathology constitutes a major reason for a vast number of patients suffering from knee pain. It is, in general, attributed either to meniscal tearing or degeneration. Debridement and partial meniscectomy, or repair, when possible, is the mainstay surgical approach for refractory knee pain from meniscal degeneration or tears. Sometimes, the patient has clinical symptoms of meniscal pathology, but despite those highly suggestive clinical symptoms, the patient turns out, during knee arthroscopy, to have meniscal degeneration and hardening of the meniscus without frank tearing of the meniscus. To initiate meniscal trephination, we first conduct a diagnostic knee arthroscopy to examine the suprapatellar space, the gutters, and the anterior knee space for any pathologies. Following this, both menisci are inspected for any signs of tearing or hardening. For the purposes of our study, the medial meniscus is considered pathological if it shows signs of degeneration or hardening, which then justifies our intervention. An 18-gauge spinal needle, manually bent for the procedure, is inserted through the portal to perform trephination on the hardened menisci. Care is taken to adequately space the needle insertion points to prevent accidental tearing. Our trephination technique aims to soften the meniscus, facilitating its ability to compact and compress when patients ambulate. Additionally, the needle insertion points help attract blood flow to the meniscus, thereby enriching it with growth factors and stem cells that may aid in improving the degenerative condition. Meniscal trephination is benign and effective for meniscal degenerative pathologies. The procedure allows for a healthier meniscus, free from degeneration, that would otherwise disable patients. The intervention does not have long-term adverse effects. To this end, more comparative trials are required to confirm the effectiveness of the technique and to ensure minimal to no associated side effects.

Arthroscopic Fixation of Posterior Cruciate Ligament Avulsion Fracture with Combined Suture Tape and Internal Bracing by Suture-bridge Technique

Background: Tibial-sided avulsion fracture of the posterior cruciate ligament (PCL) almost always require surgical intervention. Multiple techniques of reduction and fixation have been described in the literature from open/mini-open conventional screw fixation to the all-arthroscopic fixation techniques. Recent evidence shows that the all-arthroscopic fixation techniques had higher subjective and objective knee outcome scores with the advantage of addressing concomitant intra-articular injuries such as osteochondral injuries or meniscal problems. Objectives: We propose an arthroscopic fixation technique using suture tapes placed in a suture-bridge technique and combined it with internal bracing to fix tibial-sided avulsion fracture of the PCL. Surgical Technique: After routine diagnostic knee arthroscopy in supine position via standard anterolateral and anteromedial portal, two standard posteromedial and posterolateral portal was created. A standard PCL aiming guide was used to create the tibial tunnel. PCL was secured using two single-looped suture tapes around it with both limbs brought to the posterior compartment through either side of the PCL (medial and lateral). Internal bracing was done with suture tape secured to the femoral side using fixed suspensory device and brought to the posterior compartment through the lateral side of the PCL. All tapes are then passed through the tibial tunnel in a suture-bridge manner and fixed to a button in 30° flexion while reduction quality was constantly checked under direct visualization. Results: The suture bridge configuration provides direct bone-to-bone healing and secure enough fixation for early range of motion and power exercises. All-arthroscopic approach avoids posterior element related complications such as fragment comminution and neurovascular injuries. Conclusions: This technique can be considered as a safe and effective method for fixation of tibial-sided PCL avulsion fracture, which allows active mobilization with lowered risk of complications.

A Rare Cause of Knee Pain and Swelling: Venous Malformation Masquerading as Diffuse Pigmented Villonodular Synovitis

This case report recounts the history of a 21-year-old patient who presented with a 19-year history of recurrent unilateral knee pain, swelling, and restricted movement. At age 10, the patient had a diagnostic knee arthroscopy which resulted in a provisional diagnosis of pigmented villonodular synovitis. The patient was treated for this condition for several years through medical and surgical means. Despite treatment, symptoms did not resolve. Only after the case was discussed by the multidisciplinary team was further imaging through ultrasound (US) suggested. A new diagnosis of venous malformation (VM) was made after US, and the patient was treated accordingly. This case report adds to the literature examining intra-articular VMs, the use of multimodal imaging in the diagnosis of intra-articular lesions of the knee, and the importance of multidisciplinary discussion in the diagnosis of complex knee pathology.

Intelligent Algorithm-Based Magnetic Resonance for Evaluating the Effect of Platelet-Rich Plasma in the Treatment of Intractable Pain of Knee Arthritis.

The application of intelligent algorithms in the treatment of intractable pain of patients with platelet-rich plasma (PRP) knee osteoarthritis by magnetic resonance was investigated. The automatic diagnosis of magnetic resonance knee osteoarthritis was established with multiple intelligent algorithms, including gray projection algorithm, adaptive binarization algorithm, and active shape model (ASM). The difference between automatic magnetic resonance detection indexes of the patients with knee osteoarthritis and artificial measurement results was analyzed. The included patients received PRP treatment. Knee osteoarthritis MRI osteoarthritis knee scores (KOA MOAKS) and Western Ontario and McMaster Universities arthritis index (WOMAC) before and after treatment were compared. The results showed that the results of knee osteoarthritis scores, inferior angle of femur, superior angle of tibia, and tibiofemoral angle (TFA) by automatic magnetic resonance diagnostic model were entirely consistent with artificial detection results. After the treatment, the total scores of knee lateral area, interior area, central area, and patellar area were all remarkably lower than those before the treatment (P < 0.05). After the treatment, knee KOA MOAKS scores and WOMAC scores were both lower than those before the treatment (P < 0.05). Visual analogue scale (VAS) scores 1 week, 2 weeks, and 3 weeks after the treatment were decreased compared with those before the treatment (P < 0.05). Relevant studies indicated that intelligent algorithm-based automatic magnetic resonance diagnostic knee osteoarthritis model showed good utilization values, which could provide the reference and basis for the treatment of the patients with knee osteoarthritis.

Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction.

Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction.

Diagnostic Value of MRI and Radiographs of the Knee to Identify Osteochondral Lesions in Acute Patellar Instability.

The purpose of this study was to define the diagnostic value of magnetic resonance imaging (MRI) and plain radiographs (X-ray [XR]) in identifying an osteochondral defect or loose body in patients undergoing operative treatment for patellar instability. A total of 87 patients treated operatively for patellar instability with medial patellofemoral ligament (MPFL) reconstruction between 2015 and 2019 were identified. Inclusion criteria were evidence of clinical patellar instability, preoperative XR and MRI studies, and concomitant diagnostic knee arthroscopy and MPFL reconstruction performed to address patellar instability. Patients were excluded if they had a history of prior procedure for patellar instability on the surgical knee, underwent MPFL reconstruction without concomitant diagnostic knee arthroscopy, or had an anterior cruciate ligament or posterior cruciate ligament deficient knee. Operative notes and arthroscopic images were reviewed to identify osteochondral or chondral injuries and loose bodies noted during diagnostic arthroscopy. The primary outcome was the identification of intra-articular loose bodies, chondral injury, or osteochondral defect on preoperative plain radiographs and MRI in patients with patellar instability. All MRIs were performed on a 3T MRI. The sensitivity and specificity of identifying loose bodies on MRI were 0.52 and 0.92 and on XR were 0.23 and 0.98, respectively. The sensitivity and specificity of identifying osteochondral lesions on MRI were 0.43 and 0.81 and on XR were 0.08 and 0.97, respectively. Of the 87 available reports, 45 (51%) described performing chondroplasty for Outerbridge grade II/III chondral lesions on diagnostic arthroscopy. In conclusion, MRI and XR are poorly sensitive at identifying loose bodies or osteochondral defects after patellar dislocations. The poor sensitivity of imaging studies must be considered when determining whether or not to recommend operative management to a patient with patellar instability. This is a Level IV, diagnostic study.

The Diagnostic Arthroscopy Skill Score (DASS): a reliable and suitable assessment tool for arthroscopic skill training.

To develop and validate a novel score to more objectively assess the performance of diagnostic knee arthroscopy using a simulator. A Diagnostic Arthroscopy Skill Score (DASS) was developed by ten AGA (AGA-Society for Arthroscopy and Joint-Surgery) instructors for the assessment of arthroscopic skills. DASS consists of two parts: the evaluation of standardized diagnostic knee arthroscopy (DASSpart1) and the evaluation of manual dexterity, including ambidexterity and triangulation, using objective measurement parameters (DASSpart2). Content validity was determined by the Delphi method. One hundred and eleven videos of diagnostic knee arthroscopies were recorded during simulator training courses and evaluated by six specially trained instructors using DASS. Construct validity, measurement error calculated by the minimum detectable change (MDC), internal consistency using Cronbach's alpha and interrater and intrarater reliability were assessed. The Bland-Altman method was used to calculate the intrarater agreement. Six skill domains were identified and evaluated for each knee compartment. DASS, DASSpart1, and DASSpart2 showed construct validity, with experts achieving significantly higher scores than competents and novices. MDC was 4.5 ± 1.7 points for DASSpart1. There was high internal consistency for all domains in each compartment from 0.78 to 0.86. The interrater reliability showed high agreement between the six raters (ICC = 0.94). The evaluation of intrarater reliability demonstrated good and excellent agreement for five raters (ICC > 0.80) and moderate agreement for one rater (ICC = 0.68). The Bland-Altman comparison showed no difference between the first and second evaluations in five out of six raters. Precision, estimated by the regression analysis and comparison with the method of Bland and Altman, was excellent for four raters and moderate for two raters. The results of this study indicate good validity and reliability of DASS for the assessment of the surgical performance of diagnostic knee arthroscopy during simulator training. Standardized training is recommended before arthroscopy surgery is considered in patients. II.

Active vs passive haptic feedback technology in virtual reality arthroscopy simulation: Which is most realistic?

BackgroundVirtual Reality (VR) simulators are playing an increasingly prominent role in orthopaedic training and education. Face-validity - the degree to which reality is accurately represented - underpins the value of a VR simulator as a learning tool for trainees. Despite the importance of tactile feedback in arthroscopy, there is a paucity for evidence regarding the role of haptics in VR arthroscopy simulator realism. PurposeTo assess the difference in face validity between two high fidelity VR simulators employing passive and active haptic feedback technology respectively. Method38 participants were recruited and divided into intermediate and expert groups based on orthopaedic training grade. Each participant completed a 12-point diagnostic knee arthroscopy VR module using the active haptic Simbionix ARTHRO Mentor and passive haptic VirtaMed ArthroS simulators. Subsequently, each participant completed a validated simulator face validity questionnaire. ResultsThe ARTHRO Mentor active haptic system failed to achieve face validity with mean scores for external appearance (6.61), intra-articular appearance (4.78) and instrumentation (4.36) falling below the acceptable threshold (≥7.0). The ArthroS passive haptic simulator demonstrated satisfactory scores in all domains: external appearance (8.42), intra-articular appearance (7.65), instrumentation (7.21) and was significantly (p < 0.001) more realistic than ARTHRO Mentor for all metrics. 61% of participants gave scores ≥7.0 for questions pertaining to haptic feedback realism from intra-articular structures such as menisci and ACL/PCL for the ArthroS vs. 12% for ARTHRO Mentor. There was no difference in face-validity perception between intermediate and expert groups for either simulator (p > 0.05). ConclusionCurrent active haptic technology which employs motors to simulate tactile feedback fails to demonstrate sufficient face-validity or match the sophistication of passive haptic systems in high fidelity arthroscopy simulators. Textured rubber phantoms that mirror the anatomy and haptic properties of the knee joint provide a significantly more realistic training experience for both intermediate and expert arthroscopists.

Practicing Procedural Skills Is More Effective Than Basic Psychomotor Training in Knee Arthroscopy: A Randomized Study.

Background:Simulator-assisted arthroscopy education traditionally consists of initial training of basic psychomotor skills before advancing to more complex procedural tasks.Purpose:To explore and compare the effects of basic psychomotor skills training versus procedural skills training on novice surgeons’ subsequent simulated knee arthroscopy performance.Study Design:Controlled laboratory study.Methods:Overall, 22 novice orthopaedic surgeons and 11 experienced arthroscopic surgeons participated in this study, conducted from September 2015 to January 2017. Novices received a standardized introductory lesson on knee arthroscopy before being randomized into a basic skills training group or a procedural skills training group. Each group performed 2 sessions on a computer-assisted knee arthroscopy simulator: The basic skills training group completed 1 session consisting of basic psychomotor skills modules and 1 session of procedural modules (diagnostic knee arthroscopy and meniscal resection), whereas the procedural skills training group completed 2 sessions of procedural modules. Performance of the novices was compared with that of the experienced surgeons to explore evidence of validity for the basic psychomotor training skills modules and the procedural modules. The effect of prior basic psychomotor skills training and procedural skills training was explored by comparing pre- and posttraining performances of the randomized groups using a mixed-effects regression model.Results:Validity evidence was found for the procedural modules, as test results were reliable and experienced surgeons significantly outperformed novices. We found no evidence of validity for the basic psychomotor skills modules, as test scores were unreliable and there was no difference in performance between the experienced surgeons and novices. We found no statistical effect of basic psychomotor skills training as compared with no training (P = .49). We found a statistically significant effect of prior procedural skills training (P < .001) and a significantly larger effect of procedural skills training as compared with basic psychomotor skills training (P = .019).Conclusion:Procedural skills training was significantly more effective than basic psychomotor skills training regarding improved performance in diagnostic knee arthroscopy and meniscal resection on a knee arthroscopy simulator. Furthermore, the basic psychomotor skills modules lacked validity evidence.Clinical Relevance:On the basis of these results, we suggest that future competency-based curricula focus their training on full knee arthroscopy procedures. This could improve future education programs.

Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery

BackgroundThe medical community is beginning to recognize the contribution of prescription opioids in the growing national opioid crisis. Many studies have compared the safety and efficacy of alternative analgesics to opioids, but none utilizing a completely opioid-free perioperative protocol in orthopedics.MethodsWe developed and tested an opioid-free perioperative analgesic pathway (from preoperative to postoperative period) among patients undergoing common elective orthopedic procedures. Patients will be randomized to receive either traditional opioid-including or completely opioid-free perioperative medications. This study is being conducted across multiple orthopedic subspecialties in patients undergoing the following common elective orthopedic procedures: single-level or two-level ACDF/ACDA, 1st CMC arthroplasty, Hallux Valgus/Rigidus corrections, diagnostic knee arthroscopies, total hip arthroplasty (THA), and total shoulder arthroplasty/reverse total shoulder arthroplasty (TSA/RTSA). The primary outcome measure is pain score at 24 h postoperatively. Secondary outcome measures include pain scores at additional time points, medication side effects, and several patient-reported variables such as patient satisfaction, quality of life, and functional status.DiscussionWe describe the methods for a feasibility randomized controlled trial comparing opioid-free perioperative analgesics to traditional opioid-including protocols. We present this study so that it may be replicated and incorporated into future studies at other institutions, as well as disseminated to additional orthopedic and/or non-orthopedic surgical procedures. The ultimate goal of presenting this protocol is to aid recent efforts in reducing the impact of prescription opioids on the national opioid crisis.Trial registrationThe protocol was approved by the local institutional review board and registered with clinicaltrials.gov (Identifier: NCT04176783) on November 25, 2019, retrospectively registered

Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial

ObjectivesTo assess the long-term effects of arthroscopic partial meniscectomy (APM) on the development of radiographic knee osteoarthritis, and on knee symptoms and function, at 5 years follow-up.DesignMulticentre, randomised, participant- and...

The relationship between patellar lateralization diagnostic imaging markers and non-contact internal knee derangements

BackgroundTo investigate differences in the tibial tubercle-trochlear groove (TT-TG) and patellar tendon-posterior cruciate ligament (PT-PCL) distances in symptomatic patients with non-contact internal knee derangements (IKD) and symptomatic patients with internally intact knees (control).MethodsA retrospective review of MRI studies was completed by comparing 78 patients with meniscal and ligamentous derangements of the knee to 63 internally intact knees (age range, 13 to 50 years). MRI findings were reviewed independently by two board-certified radiologists to assess for agreement. TT-TG and PT-PCL distances were measured on proton density-weighted axial images by two independent observers blinded to the MRI and arthroscopic findings. Independent t tests were used to determine differences in TT-TG distance between the internal derangement and control groups. Chi-square tests were used to compare categorical variables for distributional equality between study groups.ResultsThe mean TT-TG distance averaged across the two raters in the IKD group was 11.5 mm (95% confidence interval [CI], 10.6–12.4), compared to 8.3 mm (95% CI, 7.6–9.0) in the control group (p < 0.001). The mean PT-PCL distance similarly averaged across both raters was 20.6 mm (95% CI, 19.7–21.5) for the IKD group compared to 18.2 mm (95% CI, 17.2–19.2) for the control group (p < 0.001). Among the IKD group, there were 51 meniscal tears, 12 cruciate ligament tears, and 15 tears with a combination of meniscal and cruciate findings. IKD was significantly correlated with greater TT-TG distance (p < 0.001) and greater PT-PCL distance (p < 0.003) when compared with control.ConclusionsIncreased TT-TG distances and PT-PCL distances are associated with both cartilaginous and ligamentous internal knee injuries in the present study, with TT-TG distances greater than the 12 mm representing a new threshold for concern.

Automatic segmentation algorithms and personalized geometric modelling for a human knee

Abstract Human knee is one of the most complex joints. Different reasons may lead to knee instability. A personalized mathematical model of the knee may improve both diagnostic procedure and knee surgery outcomes. Such models require accurate geometric representation of bones and attachment sites of ligaments and tendons. This paper addresses automatic segmentation of knee bones and detection of origins and insertions for tendons and ligaments. The approach is based on anatomical features of bones and landmarks of tendons/ligaments attachments on the CT images. It provides a tool for the design of patient-specific geometrical knee models.