Early Arthroscopy Research Articles

Risk of Conversion to Arthroplasty After Hip Arthroscopy: Validation of a Published Risk Score Using an Independent, Prospectively Collected Database

Background: Hip arthroscopy is rapidly advancing and increasingly commonly performed. The most common surgery after arthroscopy is total hip arthroplasty (THA), which unfortunately occurs within 2 years of arthroscopy in up to 10% of patients. Predictive models for conversion to THA, such as that proposed by Redmond et al, have potentially substantial value in perioperative counseling and decreasing early arthroscopy failures; however, these models need to be externally validated to demonstrate broad applicability. Purpose: To utilize an independent, prospectively collected database to externally validate a previously published risk calculator by determining its accuracy in predicting conversion of hip arthroscopy to THA at a minimum 2-year follow-up. Study Design: Cohort study (diagnosis); Level of evidence, 1. Methods: Hip arthroscopies performed at a single center between November 2015 and March 2017 were reviewed. Patients were assessed pre- and intraoperatively for components of the THA risk score studied—namely, age, modified Harris Hip Score, lateral center-edge angle, revision procedure, femoral version, and femoral and acetabular Outerbridge scores—and followed for a minimum of 2 years. Conversion to THA was determined along with the risk score’s receiver operating characteristic (ROC) curve and Brier score calibration characteristics. Results: A total of 187 patients (43 men, 144 women, mean age, 36.0 ± 12.4 years) underwent hip arthroscopy and were followed for a mean of 2.9 ± 0.85 years (range, 2.0-5.5 years), with 13 patients (7%) converting to THA at a mean of 1.6 ± 0.9 years. Patients who converted to THA had a mean predicted arthroplasty risk of 22.6% ± 12.0%, compared with patients who remained arthroplasty-free with a predicted risk of 4.6% ± 5.3% (P < .01). The Brier score for the calculator was 0.04 (P = .53), which was not statistically different from ideal calibration, and the calculator demonstrated a satisfactory area under the curve of 0.894 (P < .001). Conclusion: This external validation study supported our hypothesis in that the THA risk score described by Redmond et al was found to accurately predict which patients undergoing hip arthroscopy were at risk for converting to subsequent arthroplasty, with satisfactory discriminatory, ROC curve, and Brier score calibration characteristics. These findings are important in that they provide surgeons with validated tools to identify the patients at greatest risk for failure after hip arthroscopy and assist in perioperative counseling and decision making.

Is It Safe to Perform an Early Arthroscopy After a Traumatic Hip Dislocation With an Associated Pelvic Ring Injury? Report of Our Technique

Hip arthroscopy is useful in the treatment of several intra-articular pathologies, however, its use in high-energy hip and pelvis injuries raises concerns about fluid extravasion and stability of the pelvic ring. We present our arthroscopic surgical technique (initial access to the peripheral compartment) to remove intra-articular loose bodies and treat associated lesions, as well as our concerns with the technique, in case of a traumatic hip dislocation associated with a contralateral pelvic ring injury.

CORR Insights®: Does the use of ultrasound affect contamination of musculoskeletal injections sites?

This CORR Insights® is a commentary on the article “Does the Use of Ultrasound Affect Contamination of Musculoskeletal Injections Sites? by Sherman and colleagues available at: DOI: 10.1007/s11999-014-3903-4. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or the Association of Bone and Joint Surgeons®. This CORR Insights® comment refers to the article available at DOI: 10.1007/s11999-014-3903-4.

The importance of early arthroscopy in athletes with painful cartilage lesions of the ankle: a prospective study of 61 consecutive cases

BackgroundAnkle sprains are common in sports and can sometimes result in a persistent pain condition.PurposePrimarily to evaluate clinical symptoms, signs, diagnostics and outcomes of surgery for symptomatic chondral injuries of the talo crural joint in athletes. Secondly, in applicable cases, to evaluate the accuracy of MRI in detecting these injuries. Type of study: Prospective consecutive series.MethodsOver around 4 years we studied 61 consecutive athletes with symptomatic chondral lesions to the talocrural joint causing persistent exertion ankle pain.Results43% were professional full time athletes and 67% were semi-professional, elite or amateur athletes, main sports being soccer (49%) and rugby (14%). The main subjective complaint was exertion ankle pain (93%). Effusion (75%) and joint line tenderness on palpation (92%) were the most common clinical findings. The duration from injury to arthroscopy for 58/61 cases was 7 months (5.7–7.9). 3/61 cases were referred within 3 weeks from injury. There were in total 75 cartilage lesions. Of these, 52 were located on the Talus dome, 17 on the medial malleolus and 6 on the Tibia plafond. Of the Talus dome injuries 18 were anteromedial, 14 anterolateral, 9 posteromedial, 3 posterolateral and 8 affecting mid talus. 50% were grade 4 lesions, 13.3% grade 3, 16.7% grade 2 and 20% grade 1. MRI had been performed pre operatively in 26/61 (39%) and 59% of these had been interpreted as normal. Detection rate of cartilage lesions was only 19%, but subchondral oedema was present in 55%. At clinical follow up average 24 months after surgery (10–48 months), 73% were playing at pre-injury level. The average return to that level of sports after surgery was 16 weeks (3–32 weeks). However 43% still suffered minor symptoms.ConclusionArthroscopy should be considered early when an athlete presents with exertion ankle pain, effusion and joint line tenderness on palpation after a previous sprain. Conventional MRI is not reliable for detecting isolated cartilage lesions, but the presence of subchondral oedema should raise such suspicion.

A reusable suture anchor for arthroscopy psychomotor skills training

For residents to adequately develop the early arthroscopy psychomotor skills required to better learn how to manage the improvisational situations they will encounter during actual patient cases, they need to experience sufficient practice repetitions within a contextually relevant environment. Unfortunately, the cost of suture anchors can be a practice repetition–limiting factor in learning arthroscopic knot-tying techniques. We describe a technique for creating inexpensive reusable suture anchors and provide an example of their application to repair the anterior glenoid labrum during an arthroscopy psychomotor skills laboratory training session.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: pp E20

Complications of temporomandibular joint arthroscopy: A retrospective analysis of 301 lysis and lavage procedures performed using the triangulation technique

This article's introductory comments are directed towards myriad complications secondary to temporomandibular joint (TMJ) arthroscopy. Early arthroscopy, with several exceptions, was performed using single puncture techniques. Trial and error by arthroscopists gaining experience in a newly developing technique was probably the main reason for the frequency and severity of complications that occurred. The patients in this study were evaluated in a retrospective fashion. The inclusion criteria of poor response to nonsurgical therapy, preoperative magnetic resonance imaging reflecting disc displacement without reduction, general anesthesia via nasotracheal tube, antibiotic therapy, hospitalization, and the use of orthotics and physical therapy provide consistency to the study. The experience of the operator also surely must have some bearing on the complication rate.

Soft-Tissue Temporomandibular Joint Trauma

Arthroscopy, various imaging modalities, histologic studies, and clinical reviews lend support to TMJ soft-tissue injury during direct and indirect mandibular trauma. MR imaging has shown that disc displacement as well as joint effusion and soft-tissue edema are common in association with mandibular trauma (with or without fracture). In contrast, arthroscopy has shown some of the intraarticular pathologic conditions and joint effusion associated with trauma but has not described disc displacement as a major event. The arthroscopy reports also contrast the reported clinical findings of disc displacement found at the time of open reduction internal fixation of condylar fracture dislocations.8 Unfortunately, the subject of soft-tissue TMJ injury has not been well described in the literature and no well-conducted prospective studies have elucidated the proper treatment and diagnostic algorithms for this disorder. Questions remain regarding early arthroscopy or arthrocentesis to irrigate the joint space, the necessity of early joint mobilization with combined open reduction internal fixation and disc repositioning procedures, or even whether to perform MR imaging of the TMJ in the acute setting or in cervical whiplash patients. These concerns can be addressed only with further research and well-controlled studies. In the meantime, practitioners must be continually aware of the potential for soft-tissue TMJ injuries in the face of direct and indirect mandibular and facial trauma.

Jaw Joint Dysfunction and Endotracheal Intubation

To the Editor: We are concerned that the report entitled "Iatrogenic Disruptions of Right Temporomandibular Joints During Orotracheal Intubation Causing Permanent Closed Lock of the Jaw" [1] may be misinterpreted, particularly by the legal profession. Jaw joint dysfunction after anesthesia, laryngoscopy, and endotracheal intubation does not automatically imply faulty technique and may occur when appropriate care and skill have been exercised. It is important that the role of arthroscopy be properly appreciated. The condition of "closed lock" is not necessarily permanent as implied in the paper. Early arthroscopy with manipulation and lavage may correct the situation. In both the cases cited, there was a delay of several months between diagnosis and confirmatory imaging studies, and no mention was made of any arthroscopic intervention. Failure of the disk to retract normally on jaw closure may be due to causes other than "rupture of the superior retrodiscal ligament." The disk may adhere to the eminence in a "sticky joint," the so-called "suction cup effect," and this may be remedied by arthroscopy with lavage and manipulation. Furthermore, some patients have inherently lax ligaments and this leaves the joint prone to subluxation or dislocation without the use of excessive force. We are concerned that some readers unfamiliar with the complexities of the temporomandibular joint and its disorders might conclude that joint dysfunction after laryngoscopy or intubation necessarily implies defective technique. Such is emphatically not the case. We failed to obtain a response from Dr. Gould. Philip Worthington, MD, BSc, FDSRCS Department of Oral and Maxillofacial Surgery University of Washington School of Dentistry Seattle, WA 98195-7134 Frederick W. Cheney, MD Department of Anesthesiology University of Washington School of Medicine Seattle, WA 98195-6540

Jaw Joint Dysfunction and Endotracheal Intubation

To the Editor: We are concerned that the report entitled "Iatrogenic Disruptions of Right Temporomandibular Joints During Orotracheal Intubation Causing Permanent Closed Lock of the Jaw" [1] may be misinterpreted, particularly by the legal profession. Jaw joint dysfunction after anesthesia, laryngoscopy, and endotracheal intubation does not automatically imply faulty technique and may occur when appropriate care and skill have been exercised. It is important that the role of arthroscopy be properly appreciated. The condition of "closed lock" is not necessarily permanent as implied in the paper. Early arthroscopy with manipulation and lavage may correct the situation. In both the cases cited, there was a delay of several months between diagnosis and confirmatory imaging studies, and no mention was made of any arthroscopic intervention. Failure of the disk to retract normally on jaw closure may be due to causes other than "rupture of the superior retrodiscal ligament." The disk may adhere to the eminence in a "sticky joint," the so-called "suction cup effect," and this may be remedied by arthroscopy with lavage and manipulation. Furthermore, some patients have inherently lax ligaments and this leaves the joint prone to subluxation or dislocation without the use of excessive force. We are concerned that some readers unfamiliar with the complexities of the temporomandibular joint and its disorders might conclude that joint dysfunction after laryngoscopy or intubation necessarily implies defective technique. Such is emphatically not the case. We failed to obtain a response from Dr. Gould. Philip Worthington, MD, BSc, FDSRCS Department of Oral and Maxillofacial Surgery University of Washington School of Dentistry Seattle, WA 98195-7134 Frederick W. Cheney, MD Department of Anesthesiology University of Washington School of Medicine Seattle, WA 98195-6540

Conservative treatment of isolated injuries to the posterior cruciate ligament in athletes

We assessed arthroscopically 22 young athletes with an isolated acute posterior cruciate ligament (PCL) injury. Four had significant damage to the articular cartilage of the medial femorotibial compartment and were advised not to resume sports. Three underwent PCL reconstruction because of a reparable meniscal tear or instability. The other 15 were treated conservatively and resumed sport. At an average follow-up of 51 months, one had developed arthritic symptoms due to newly-developed severe chondral damage to the medial femoral condyle, but none of the other 14 had developed arthritic symptoms and most remained athletically active. Severe chondral damage should be seen at an early arthroscopy. Knees with an isolated injury to the PCL with concomitant articular damage may be successfully managed by conservative treatment.

Hemarthrosis of the Clinically Stable Knee Due to Sports and Military Training in Young Recruits: An Arthroscopic Analysis

Findings of an early arthroscopy performed in 108 consecutive hemarthrotic and clinically stable knees were analyzed. The patients were young conscripts, the mean age being 19.9 years. Fifty-seven of the knees were injured during military training, 36 in different sports activities, 9 at falls, and 6 in motorbike accidents. The lesions were divided into "primary" (lesions needing operative treatment or the supposed most common lesions in incidence) and "secondary" (other lesions). An average of 1.6 lesions were observed per knee. Dislocation of the patella was the most common diagnosis in 38 (35%) cases. Dislocation of the patella was associated with military exercise (p < 0.001). Lesions of the anterior cruciate ligament (ACL) were observed in 37 (34%) cases. ACL ruptures were related to sport activities (p < 0.0001).

Arthroscopy in acute knee injuries: A prospective controlled trial

Eighty-two patients took part in a prospective trial to assess the need and timing for arthroscopy in acute knee injuries. Patients with a suspected ligament injury, a suspected meniscal tear, or a haemarthrosis in the absence of fracture were included in the trial. Patients were entered randomly into two groups. In group I early arthroscopy was performed (within 48 h), in group II arthroscopy was performed within 21 days, but only when it was felt to be clinically indicated. Patients were assessed using the OAK knee score 1 year after the injury. There was no difference in the final result between the two groups. Early arthroscopy (within 48 h) showed no beneficial effect when compared with delayed arthroscopy (3 to 21 days after the injury). Indeed, an important diagnosis was missed at early arthroscopy in three cases, which led to delay in subsequent diagnosis and treatment. Arthroscopy raised the diagnostic accuracy from 61 per cent to 93 per cent. Considerable morbidity arises as a result of acute knee injuries. Clinical judgement will correctly define the need for arthroscopy in most cases at the time of injury, and arthroscopy is not necessary in all cases of acute haemarthrosis.