Joint Irrigation Research Articles

Septic arthritis of the knee: Presentation of a novel irrigation-suction system tested in a cadaver study

BackgroundThe established treatment for bacterial arthritis of the knee joint is arthroscopic surgery with irrigation and debridement. The aim of this article is to summarize the relevant data in treating bacterial arthritis of the knee joint, and based on these findings to present a novel irrigation suction system, tested in a cadaver study, as an additional tool in the postoperative treatment phase of arthroscopic surgery for knee joint infections.MethodThe novel automated irrigation-suction system presented here was compared to conventional continuous suction irrigation in a total of six knee joints. All knee joints were filled with 80 ml methylene blue stain and rinsed by two different methods. Fluid specimens were taken after ten and twenty minutes to be compared by photometric extinction measurement at a wave length of 500 nm.ResultsAfter ten minutes, the average extinction was e1C = 0.8 for the continuous suction irrigation and e1N = 0.4 for the novel irrigation-suction system. After twenty minutes, we recorded an average extinction of e2C = 0.3 for continuous suction irrigation and e2N = 0.001 for the novel irrigation-suction system. The students t-test revealed superior results after ten and twenty minutes of washing out the knee joints with a p < 0.001 for the novel irrigation-suction system.ConclusionA novel irrigation-suction system may be an effective tool for postoperative knee joint irrigation in arthroscopic therapy for bacterial arthritis of the knee. Further animal studies are needed to verify the effects in vivo.

Concentric-Needle Cannula Method for Single-Puncture Arthrocentesis in Temporomandibular Joint Disease: An Inexpensive and Feasible Technique

Management of temporomandibular joint (TMJ) disorders presenting with pain, restricted mouth opening, or simply asymptomatic clicking can be challenging even to the experienced surgeon. Many conservative and invasive techniques are available, but most cases can be treated by arthrocentesis of the joint locally. A simple process of joint irrigation enables lysis of intra-articular adhesions, change in the joint viscosity, and clearance of various substances in the joint fluid. Classically, arthrocentesis of the TMJ has been performed with 2 needles: an infusion needle and an aspiration needle. Various devices and techniques have been described in the literature, each with its own benefits and drawbacks. We introduce our technique of TMJ lavage using 2 different gauge needles placed in a concentric manner; hence, besides a less traumatic and easier puncture of the joint capsule, the lavage and aspiration of the joint space can be performed efficiently, with minimal morbidity. The use of a concentric-needle cannula system is the least traumatic and perhaps the most cost-effective method for TMJ lavage described to date. We believe that this technique is applicable and can be performed by even the inexperienced surgeon.

Current concepts review: Septic arthritis of the knee pathophysiology, diagnostics, and therapy

Treatments for bacterial arthritis of the knee joint are arthroscopic irrigation and debridement with systemic antibiotic medication. This article summarizes the relevant data of pathophysiology, stage of infection, symptoms, and diagnostics as well as stage-dependent treatment of bacterial arthritis of the knee joint. The major treatment principles are joint decompression, elimination of the causative organisms by intensive irrigation of the joint with elimination of proteolytic and lysosomal enzymes. Debridement of necrotic soft tissues with the aim of preserving the synovial membrane as an immune-competent structure, and a natural barrier, is recommended. Good results in treating knee infections have been achieved with arthroscopic joint revision and stage-dependent surgical therapy. The infection staging I-IV suggested by Gächter was used most commonly, which mainly reflects the pathophysiologic infection stages. For stages I-III, arthroscopic joint decompression with joint irrigation and debridement is effective and can be repeated in cases of persisting infection. The incidence of repeated arthroscopic joint irrigation depends on the initial stage of the infection and varies between 0 and 41% of the cases. For stage IV infections, the open revision is needed or in seldom cases of therapy failure under initial or repeated arthroscopic joint revision. The success rate of healing infections by arthroscopic irrigation was high with 90-100%.

Percutaneous Aspiration Irrigation Drainage Technique in the Management of Septic Arthritis in Children

Septic arthritis in childhood is a therapeutic emergency. The authors present their experience using an intermediate technique with the advantages of the percutaneous aspiration irrigation drainage: joint aspiration, irrigation, and declivious drainage. All children were treated by joint aspiration under fluoroscopic control, large volume irrigation, and declivious nonsuction drainage associated with immobilization and intravenous antibiotics during 8 days to 10 days. The draining system was removed when clinical improvement (namely apyrexia) and the decrease of biological inflammatory response were obtained. A late follow-up phone interview was made for each patient. Fifty-two patients were included in this study, with a mean age of 4.3 years. The most common sites of arthritis were the hip (19 of 52, 36%) and the knee (17 of 52, 32%), but ankle (8 of 52, 15%), shoulder (12%), and elbow (3%) were also involved. Apyrexia was obtained after a mean period of 2 days. The mean draining duration was 4.5 days. On the last follow-up visit (at 21 months on average; range, 12-56 months), all patients except one were totally painless and had no limitation of physical activity. Percutaneous aspiration irrigation drainage assured very good results in this study population, with rapid clinical and biological improvement and the absence of long-term sequelae. The advantages of this technique include permanent joint access and control of synovial effusions, with only one general anesthesia and minimal iatrogenic morbidity.

Hyperosmolarity protects chondrocytes from mechanical injury in human articular cartilage

The aim of this study was to determine whether exposure of human articular cartilage to hyperosmotic saline (0.9%, 600 mOsm) reduces in situ chondrocyte death following a standardised mechanical injury produced by a scalpel cut compared with the same assault and exposure to normal saline (0.9%, 285 mOsm). Human cartilage explants were exposed to normal (control) and hyperosmotic 0.9% saline solutions for five minutes before the mechanical injury to allow in situ chondrocytes to respond to the altered osmotic environment, and incubated for a further 2.5 hours in the same solutions following the mechanical injury. Using confocal laser scanning microscopy, we identified a sixfold (p = 0.04) decrease in chondrocyte death following mechanical injury in the superficial zone of human articular cartilage exposed to hyperosmotic saline compared with normal saline. These data suggest that increasing the osmolarity of joint irrigation solutions used during open and arthroscopic articular surgery may reduce chondrocyte death from surgical injury and could promote integrative cartilage repair.

Risk factors for the poor clinical outcome of visually guided temporomandibular joint irrigation in patients with chronic closed lock

Objective This study aimed to explore the risk factors of poor clinical outcome of visually guided irrigation (VGIR) in patients with chronic closed lock (CCL) of the temporomandibular joint (TMJ). Materials and methods Sixty-one patients with unilateral CCL who underwent a VGIR were enrolled in this study. At the 3-month follow-up after VGIR, the 61 patients were divided into either the good outcome (g-) group ( n = 37) or poor outcome (p-) group ( n = 24), according to the clinical success criteria. Age, gender, duration of symptoms, preoperative painless range of mandibular motion (P-ROM), preoperative TMJ pain, muscle symptoms, MRI findings (the severity of bony change, disc deformity and joint effusion), and arthroscopic findings (the severity of osteoarthritic change, synovial lesion and fibrous adhesion) were selected as the candidates of prognostic factors for VGIR. Each factor was compared between the two groups. Moreover, multiple logistic regression analysis was performed. Result The preoperative P-ROM of the p-group was significantly lower than that of the g-group. The severity of osteoarthritic change in the p-group was significantly greater than that of the g-group. Regarding the MRI findings, there were no significant differences between the two groups. The multivariate adjusted odds ratio showed that only a decreased preoperative P-ROM was significantly predictive for a poor clinical outcome of VGIR. Conclusion A pronounced decrease of preoperative P-ROM would be a significant risk factor for a poor clinical outcome of TMJ irrigation in patients with CCL.

Outcome of management of non-gonococcal septic arthritis at national orthopaedic hospital, Enugu, Nigeria

Septic arthritis is an accute bacterial infection of a synovial joint. It is an orthopaedic emergency that can lead to morbidity or mortality if not properly treated. the fundamental issues in the management of septic arthritis include the duration of antibiotic therapy, the mode of joint drainage and the role of physiotherapy. There is a paucity of local data on septic arthritis in Nigeria. The study wa carried out at the National Orthopoedic Hospital, Enugu; a regional trauma and orthopaedic center with wide catchments area covering at least three geopolitical zones of Nigeria. The objective of the study is to describe the pattern and distribution of non-gonococcal septic arthritis, the causative organisms, and the outcome of management of this condition at Enugu, Nigeria and make recommendations on the antibiotic therapy. A retrospective study of all the patients that presented at the National Orthopaedic Hospital Enugu with Non-gonococcal septic arthritis between January 1997 and December, 2006 was done. The patient's case notes were retrieved from the Medical Record Department. Information extracted and analyzed included demographic data, joints affected, cultured organisms, antibiotic sensitivity pattern, duration of parenteral and oral antibiotics therapy, complications and follow-up period. Patients with incomplete records, immune-compromised patients and those with subjacent osteomyelitis were excluded from the study. Forty-three patients were seen within the period and 40 had analyzable data. The age range was 1 month to 39 years, with a mean age of 10.2 years. Twenty-one patients (52.5%) were males and 19 (47.5%) were females. The hip joint was the most commonly affected (47.5%). Staphylococcus aureus was the most common organism (50%), followed by Coliformn (42.5%). Most patients (75%) had parenteral antibiotics for 3-5 days, while 77.5% of patients received oral antibiotics for 2-4 weeks. All the patients had arthrotomy and joint irrigation within 48 hours of admission. Complicatins were recorded in 11 patients (27.5%). Fixed flexion deformity was the commonest complication (17.5%). No mortality was recorded. Septic arthritis is an orthopaedic emergency. Early diagnosis and prompt treatment with appropriate ontibiiotics and surgical drainage are the keys to a successful outcome. In our environment (Enugu), the coliforms ore competing favourably with stophylococcus oaureus as causative agents of septic arthritis. Short term parenteral antibiotics of 3-5 days seems to be as effective as the 1-2 weeks therapy in the non-immune compromised patients and in cases not complicated by juxtarticular osteomyehlitis or presence of prosthetic implants.

The levels of vascular endothelial growth factor in the synovial fluid correlated with the severity of arthroscopically observed synovitis and clinical outcome after temporomandibular joint irrigation in patients with chronic closed lock

This study aimed to investigate the level of vascular endothelial growth factor (VEGF) in the temporomandibular joint (TMJ) synovial fluid (SF) and the severity of arthroscopically observed synovitis before and after visually guided TMJ irrigation (VGIR) in patients with chronic closed lock (CCL). In addition, the findings were correlated with the clinical outcome. Twenty-four patients with unilateral CCL, who underwent a second VGIR either as a repeated therapeutic TMJ irrigation or as a follow-up arthroscopy, were enrolled in the study. They were divided into either successful (s-group; n = 11) and unsuccessful (u-group; n = 13) groups. The VEGF level in the aspirated SF and the severity of synovitis were compared between the s- and u-groups. In each group, the same parameters were compared before and after VGIR. The correlation of the VEGF level with the severity of synovitis was also studied. At the first VGIR, the VEGF levels showed no significant differences when comparing s- and u-groups. At the second VGIR, the VEGF level was significantly higher in the u-group. The VEGF level significantly decreased after the first VGIR in the s-group but remained unchanged in the u-group. There was no significant correlation between the VEGF level and the severity of synovitis. The level of VEGF in TMJ SF seems to reflect the clinical status in patients with CCL. Moreover, VEGF may be an important target molecule in future chemotherapy of TMJ CCL.

Increasing the Osmolarity of Joint Irrigation Solutions May Avoid Injury to Cartilage: A Pilot Study

Saline (0.9%, 285 mOsm) and Hartmann's solution (255 mOsm) are two commonly used joint irrigation solutions that alter the extracellular osmolarity of in situ chondrocytes during articular surgery. We asked whether varying the osmolarity of these solutions influences in situ chondrocyte death in mechanically injured articular cartilage. We initially exposed osteochondral tissue harvested from the metacarpophalangeal joints of 3-year-old cows to solutions of 0.9% saline and Hartmann's solution of different osmolarity (100-600 mOsm) for 2 minutes to allow in situ chondrocytes to respond to the altered osmotic environment. The full thickness of articular cartilage then was "injured" with a fresh scalpel. Using confocal laser scanning microscopy, in situ chondrocyte death at the injured cartilage edge was quantified spatially as a function of osmolarity at 2.5 hours. Increasing the osmolarity of 0.9% saline and Hartmann's solution to 600 mOsm decreased in situ chondrocyte death in the superficial zone of injured cartilage. Compared with 0.9% saline, Hartmann's solution was associated with greater chondrocyte death in the superficial zone of injured cartilage, but not when the osmolarity of both solutions was increased to 600 mOsm. These experiments may have implications for the design of irrigation solutions used during arthroscopic and open articular surgery.

Physical Simulation Environment for Arthroscopic Joint Irrigation

Good arthroscopic view is important to perform arthroscopic operations (minimally invasive surgery in joints) safely and fast. To obtain this, the joint is irrigated. However, optimal irrigation settings are not described. To study the complex clinical practice of irrigation, a physical simulation environment was developed that incorporates the main characteristics for performing arthroscopy. Its irrigation capacities were validated with patient data. The physical simulation environment consists of a specially designed knee phantom, all normally used arthroscopic equipment, and registration devices for two video streams, pressures, and flows. The physical embodiment of the knee phantom matches that of human knee joints during arthroscopic operations by the presence of important anatomic structures in sizes comparable to human knee joints, the presence of access portals, and the ability to stress the joint. The hydrostatic and hydrodynamic behavior of the knee phantom was validated with pressure and flow measurements documented during arthroscopic knee operations. Surgeons confirmed that the knee phantom imitated human knee joints sufficiently. The hydrostatic parameters of the knee phantom could be tuned within the range of the human knee joints (restriction: 0.0266–29.3 N s2/m8 versus 0.0143–1.22×1018 N s2/m8 and capacitance: 6.89 m5/N versus 7.50×10−9 m5/N). The hydrodynamic properties of the knee phantom were acceptably comparable to those of the human knee joints. The physical simulation environment enables realistic and conditioned experimental studies to optimize joint irrigation. The foundation has been laid for evaluation of other surgical instruments and of training of surgical skills.

Chondrocyte death in mechanically injured articular cartilage—the influence of extracellular calcium

Calcium is thought to be an important regulator of chondrocyte death associated with articular cartilage injury. Our objective was to determine the influence of extracellular calcium on chondrocyte death following mechanical injury. Using a surgically relevant model of sharp mechanical injury (with a scalpel) and confocal laser scanning microscopy (CLSM), in situ chondrocyte death was quantified within the full thickness of articular cartilage as a function of medium calcium concentration and time (2.5 h and 7 days). Exposure of articular cartilage to calcium-free media (approximately 0 mM) significantly reduced superficial zone chondrocyte death after mechanical injury compared with exposure to calcium-rich media (2-20 mM, ANOVA at 2.5 h, p = 0.002). In calcium-rich media, although the extent of chondrocyte death increased with increasing medium calcium concentration, cell death remained localized to the superficial zone of articular cartilage over 7 days (ANOVA, p < 0.05). However, in calcium-free media, there was an increase in chondrocyte death within deeper zones of articular cartilage over 7 days. The early (within hours) chondroprotective effect in calcium-free media suggests that the use of joint irrigation solutions without added calcium may decrease chondrocyte death from mechanical injury during articular surgery. The delayed (within days) increase in chondrocyte death in calcium-free media supports the use of calcium supplementation in media used during cartilage culture for tissue engineering or transplantation.

Man With Right Knee Injury

[Ann Emerg Med. 2009;53:425.] A 26-year-old man presented to the emergency department with a chief complaint of a right knee injury sustained shortly before admission. He flipped his bicycle and struck his right knee on a rock, sustaining a laceration. The patient described a gush of fluid from the laceration when he attempted to stand, and he was unable to walk because of severe knee pain. Physical examination revealed a 3-cm transverse laceration of the distal anterolateral right thigh, approximately 8 cm proximal to the patella. The knee examination showed tenderness in the peripatellar areas, no effusion, normal but painful range of motion, and normal neurovascular and tendon exams. Knee radiograph results were negative for bony abnormalities, foreign body, or intraarticular air. Methylene blue was instilled into the joint through a medial approach, and it extravasated from the laceration (Figure 1, Figure 2).Figure 2Lateral view, methylene blue arthrogram, right knee. Used with permission of David M. Lemonick, MD, Emergency Department, Highlands Hospital, Connellsville, PA.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The knee is the major joint most frequently involved in open joint injuries.1Carr N.J. Gallico G. Soft tissue injuries and management about the knee.in: Siliski J.M. Traumatic Disorders of the Knee. Springer-Verlag, New York, NY1994: 62Google Scholar In the civilian setting, gunshot wounds and motor vehicle crashes are responsible for the majority of these wounds. An open joint may result from direct penetration of the joint or by extension into the knee of a compound periarticular fracture. Knee dislocations are open in 20% to 30% of cases.1Carr N.J. Gallico G. Soft tissue injuries and management about the knee.in: Siliski J.M. Traumatic Disorders of the Knee. Springer-Verlag, New York, NY1994: 62Google Scholar Any deep wound in proximity to a joint should be suspected of being an open joint injury. Detection of an open joint may be immediately evident on inspection of the wound, or it may be subtle, requiring adjunctive testing. The criteria for making the diagnosis include a visible or palpable opening into the joint, air or foreign bodies in the joint on radiographic examination, or saline solution extravasation through the wound on arthrocentesis.2Mandavia D. Newton E.J. Demetriades D. Color Atlas of Emergency Trauma. Cambridge University Press, Cambridge, England2003Crossref Google Scholar In questionable cases, methylene blue may be added to the arthrocentesis irrigant. Initial treatment requires meticulous debridement of the wound and broad-spectrum antibiotics. All major open joint injuries require formal operative joint exploration and irrigation.2Mandavia D. Newton E.J. Demetriades D. Color Atlas of Emergency Trauma. Cambridge University Press, Cambridge, England2003Crossref Google Scholar

Supporting the Shift from State Water to Community Water: Lessons from a Social Learning Approach to Designing Joint Irrigation Projects in Morocco

This paper focuses on the evaluation of a participatory approach aimed at supporting groups of small-scale farmers in the design of joint drip irrigation projects. Our idea was to create a sustainable social learning environment in which they could acquire adaptive knowledge about new irrigation technology and about designing and managing a joint irrigation project while at the same time improving their negotiation capacities. We developed a framework to evaluate the process as well as the outputs and outcomes of the use of our approach with four groups of smallholder farmers in the Tadla irrigation scheme in Morocco. Our findings showed that the learning environment made it possible to compensate for the knowledge differential among stakeholders and to co-produce knowledge that can be mobilized by small-scale farmers to help them make better informed decisions when choosing whether or not to engage in a joint irrigation project and when developing and implementing such a project. We expect that this will ultimately contribute to supporting the shift from state water to community water through a shared understanding of the technical, economic, and social issues and options related to the management of irrigation water. (Resume d'auteur)

Severity of arthroscopically observed pathology and levels of inflammatory cytokines in the synovial fluid before and after visually guided temporomandibular joint irrigation correlated with the clinical outcome in patients with chronic closed lock

This study aimed to investigate the severity of arthroscopically observed pathologies and the levels of a set of inflammatory cytokines in aspirated synovial fluid (A-SF) in patients with chronic closed lock (CCL) of the temporomandibular joint (TMJ) before and after visually guided TMJ irrigation (VGIR). Furthermore, the findings were correlated with the clinical outcome after VGIR. VGIR was performed in 56 consecutive patients with unilateral CCL. Forty-nine of them, who underwent a second VGIR either as a follow-up arthroscopy or as a repeated therapeutic irrigation, were analyzed. They were assigned to either the successful (s-) group (n = 31) or unsuccessful (u-) group (n = 18), according to the clinical success criteria. The severity of arthroscopic findings of osteoarthritis (OA), synovitis, and fibrous adhesion (FA) were evaluated as arthroscopic scores. The levels of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6, IL-8, IL-12, and IL-10 in the A-SF were measured. At the first and second VGIR, the arthroscopic scores and the levels of each investigated cytokine were compared between the s- and u-groups. In each group, same parameters were compared between the first and second VGIR. At the first and second VGIR, there are no differences in the arthroscopic scores between the s- and u-groups. After the first VGIR, the severity of synovitis significantly improved, that of OA was unchanged, and that of FA became worse in the s- and u-groups. At the first VGIR, the levels of IL-6 and IL-8 were significantly higher in the u-group, and the IL-10 level was significantly higher in the s-group. At the second VGIR, however, there were no differences in the levels of each investigated cytokine between the s- and u-groups. The levels of each cytokine did not significantly change between the first and second VGIR, regardless of the clinical outcome. VGIR may contribute to the remission of synovitis in patients with TMJ CCL. However, the severity of arthroscopically observed pathologies and the levels of each investigated cytokine do not seem to be reflected by the clinical state. Moreover even if the intra-articular inflammation is asymptomatic, an exacerbation may not be ruled out even after a successful VGIR.

Interventional radiology of synovial chondromatosis in the temporomandibular joint using a thin arthroscope

This case report describes, for the first time, the use of interventional radiology following arthroscopy with a thin arthroscope for the diagnosis and treatment of synovial chondromatosis (SC) of the temporomandibular joint (TMJ). Therapeutic joint irrigation concomitant with arthroscopic observation of the superior joint compartment (SJC) was performed in a patient with functional TMJ pain caused by SC. The thin arthroscope was inserted with the aid of an X-ray fluoroscope. Arthroscopy confirmed that the SC was at disease stage II and that synovitis existed throughout the SJC. The initial maximal interincisor opening (MIO) was 30 mm, while after the joint-irrigation procedure the MIO was 40 mm. In addition, the TMJ pain was greatly reduced after joint irrigation. Our findings demonstrate that interventional radiology with a thin arthroscope is clinically useful for the diagnosis and primary treatment of patients with painful SC in the TMJ.

Experimental approach to study arthroscopic irrigation

The view during arthroscopic operations is kept clear by means of irrigation. The purpose was to determine dominant parameters on irrigation performance from which design considerations were formulated for optimization of joint irrigation. An experimental approach was chosen. The set up consisted of a human joint phantom with normal operative equipment for irrigation. Disturbances of the view were simulated with blue colored ink. With this, an objective and quantitative outcome measure was defined as the time from ink injection till complete clear view (irrigation time). The irrigation times for varying parameters were evaluated: pressure and flow, configuration of in- and outflow portals, location of bleeding, two- versus three-dimensionally shaped joint space, direction and location of inflow, and presence of an instrument. Apart from the level of pressure and flow ( F(5,34) = 245, p < 0.05), the configuration of in- and outflow portals had a dominant significant influence on the irrigation time ( F(2,23) = 69, p < 0.05) achieving a decrease of up to 64% and 77%, respectively. The experimental approach resulted in formulation of design criteria for new sheaths: cross-sectional area as large as possible, and stimulation of a turbulent inflow. The method can be used as a standard testing protocol for new arthroscopic devices and instruments.

Present Situation and Challenges of Joint Irrigation Management by the Government and Farmers in Sri Lanka

Present Situation and Challenges of Joint Irrigation Management by the Government and Farmers in Sri Lanka

Cytokine and Clinical Predictors for Treatment Outcome of Visually Guided Temporomandibular Joint Irrigation in Patients With Chronic Closed Lock

This study investigates selected predictors for clinical outcome of temporomandibular joint (TMJ) irrigation in patients with chronic closed lock (CCL). Fifty-six patients with unilateral CCL, who underwent a visually guided TMJ irrigation (VGIR), were enrolled in this study. They were divided into either successful (s-group; n = 38) or unsuccessful groups (u-group; n = 18), according to the clinical success criteria. The investigated predictive factors were age, gender, duration of symptoms before the VGIR, preoperative painless range of mandibular motion, preoperative self-evaluated TMJ pain on visual analog scale (VAS), severity of arthroscopically observed pathologies, and presence and concentrations of a set of pro- and anti-inflammatory cytokines (ie, tumor necrosis factor [TNF]-alpha, interleukin [IL]-1beta, IL-6, IL-8, IL-12, and IL-10) in the aspirated synovial fluid (A-SF). Several comparative analyses and logistic regression analyses were used for statistical studies. The preoperative VAS score, detection rate of IL-8, and concentrations of IL-6 and IL-8 in the A-SF were significantly higher in the u-group (P < .05). Conversely, the detection rate and concentrations of IL-10 were significantly higher in the s-group (P < .05). The multivariate adjusted odds ratio (OR) showed that the detectable IL-10 in the A-SF (OR, 10.882; P = .047) is significantly predictive for a successful VGIR. The presence of IL-10 in the A-SF is a significant predictor of successful outcome of TMJ irrigation for CCL. Severe TMJ pain and detectable IL-6 or IL-8 in the A-SF seem to indicate a poor outcome after TMJ irrigation.

Guidelines to Becoming an Expert Elbow Arthroscopist

This report presents my guidelines for surgeon training and development of skills in the art of elbow arthroscopy. As elbow arthroscopy becomes more common, it is important to achieve greater levels of experience that will minimize the risk of complications because indications and techniques are growing in number and complexity. Indications for elbow arthroscopy that require diagnosis before open surgery include evaluation of instability; removal of loose bodies, spurs, and plica; irrigation and debridement of infection or open joints; evaluation for arthrofibrosis (with open nerve protection), lateral epicondylitis, arthritis, osteochondritis dissecans, fracture, bursectomy, synovectomy, stabilization, tendon repair, and nerve release or decompression.

The Changes in Arthroscopic Findings and Inflammatory Cytokine Levels in the Synovial Fluid After Visually Guided Temporomandibular Joint Irrigation

This study aimed to explore the changes in arthroscopic findings and levels of a set of inflammatory cytokines in the aspirated synovial fluid (A-SF) after visually guided TMJ irrigation (VGIR) in patients with chronic closed lock (CCL). Moreover, the correlation of the obtained findings with the clinical outcome of VGIR was studied.