Therapeutic Arthroscopy Research Articles

Association of lumbar plexus block and sciatic nerve block as alternative loco-regional technique to rachianesthesia for therapeutic knee arthroscopy

Association of lumbar plexus block and sciatic nerve block as alternative loco-regional technique to rachianesthesia for therapeutic knee arthroscopy

A new arthroscopic technique for revision of the posterior compartment in symptomatic total knee arthroplasty

Arthroscopy is effective in treating the symptomatic knee following total knee arthroplasty. A small number of patients complain about postoperative pain in the posterior compartment. Loose bodies and degenerated remnants of the menisci are the main reasons for this pain. We present a new technique for diagnostic and therapeutic arthroscopy of the posterior compartments in patients with symptomatic total knee arthroplasty. After standard anterior arthroscopy, a wide circular notchplasty is performed to allow easy access to the posterior lateral compartment of the knee joint and to apply a posterolateral working portal under direct arthroscopic control. If inspection of the posteromedial compartment is necessary, the loose tissue behind the posterior cruciate ligament is resected to gain access to the posteromedial compartment.

Chondral degeneration and therapeutic hip arthroscopy

Therapeutic hip arthroscopy for the treatment of chondral degeneration remains controversial. A retrospective cohort study examined 70 patients of mean age 47 (range 22-87) years who had undergone hip arthroscopy and assessed them for evidence of chondral degeneration using radiological and arthroscopic means. Clinical outcome was assessed using a modified Farjo and Glick classification. Thirty-nine patients had evidence of chondral degeneration on arthroscopy with or without radiological diagnosis, and 31 had alternative pathology. If patients were found to have chondral degeneration at arthroscopy, they were significantly more likely to have a poor clinical result than if an alternative diagnosis such as a loose body or labral tear was made (p<0.0001). Patients with evidence of degenerative changes on plain hip radiographs were significantly more likely to have a poor clinical result following hip arthroscopy than patients with unremarkable hip radiographs (p<0.0001). Therapeutic hip arthroscopy for osteoarthritis should be used with caution, as a poor clinical result is significantly more likely compared to other pathologies such as a labral tear or loose body.

Trends in utilization: has extremity MR imaging replaced diagnostic arthroscopy?

To examine the relative change in utilization of magnetic resonance (MR) imaging of the extremities versus diagnostic and therapeutic arthroscopy. Using the 1993, 1996, and 1999 nationwide Medicare Part B databases, utilization rates (per 100000) were determined for upper and lower extremity MR imaging, diagnostic arthroscopy and therapeutic arthroscopy using CPT-4 codes. Utilization of extremity MR imaging was compared with that of diagnostic and therapeutic arthroscopy in 10 geographic regions of the United States and tracked over time. Combined lower and upper extremity MR imaging utilization per 100000 increased from 393 to 1056 in 1999 (+168.7%). Utilization of diagnostic arthroscopy of the extremities decreased from 18 in 1993 to 8 in 1999 (-55.6%); therapeutic arthroscopy rates increased from 461 in 1993 to 636 in 1999 (+40.0%). Specifically, from 1993 to 1999, utilization of lower extremity MR imaging increased from 270 to 661 (+144.8%). Utilization of diagnostic arthroscopy of the knee over the same time period decreased from 11 to 5 (-54.5%); therapeutic arthroscopy increased from 394 to 501 (+27.2%). Similarly, utilization rates for upper extremity MR imaging increased from 123 to 395 (+221.1%). Utilization of diagnostic arthroscopy of the shoulder over the same time period decreased from 7 to 2 (-71.4%); therapeutic arthroscopy increased from 44 to 104 (+136.4%). No specific geographic trends were ascertained. The utilization of MR imaging of the extremities has markedly increased from 1993 to 1999. During the same time period the utilization of diagnostic arthroscopy has decreased and that of therapeutic arthroscopy has increased. These findings support the hypothesis that there is increased reliance of clinical practitioners on the diagnostic information provided by MR imaging in preoperative clinical decision-making.

Bone morphogenetic proteins 2 and 6, expressed in arthritic synovium, are regulated by proinflammatory cytokines and differentially modulate fibroblast-like synoviocyte apoptosis.

To examine the expression, regulation, and potential roles of bone morphogenetic proteins (BMPs) in arthritic synovium. Expression of BMPs in arthritic synovium from patients with rheumatoid arthritis (RA) or spondylarthropathy (SpA) and in noninflamed synovium from patients undergoing diagnostic or therapeutic arthroscopies was studied by reverse transcription-polymerase chain reaction (RT-PCR), Western blot, immunohistochemistry, and 2-color immunofluorescence. In vitro regulation of gene expression in fibroblast-like synoviocytes (FLS) was determined by real-time quantitative RT-PCR and immunohistochemistry. We used (3)H-thymidine incorporation after serum deprivation-induced growth arrest to examine effects on FLS proliferation. FLS apoptosis was evaluated by flow cytometry cell cycle analysis. Apoptotic cells in synovial tissue were detected by TUNEL staining. Transcripts of different BMPs, most strikingly BMP-2 and BMP-6, were detected in synovial tissues. By Western blot, BMP-2 and BMP-6 precursor protein was found in RA and SpA synovial tissue extracts, but not in extracts of noninflamed synovial tissue. By immunohistochemistry, BMP-2 and BMP-6 were detected in the hyperplastic lining and the sublining layer of synovium from RA and SpA patients, both in CD90+ cells (FLS) and in some CD68+ cells (macrophages). Proinflammatory cytokines, such as interleukin-1beta and tumor necrosis factor alpha, but not interferon-gamma, enhanced the expression of BMP-2 and BMP-6 transcripts in FLS in vitro. Neither BMP-2 nor BMP-6 affected FLS proliferation. BMP-2 promoted FLS apoptosis, whereas BMP-6 protected against nitric oxide-induced FLS apoptosis. BMP-2-positive apoptotic cells were found in arthritic synovium. BMP-2 and BMP-6 are expressed in arthritic synovium and are strongly up-regulated by proinflammatory cytokines. Although BMP signaling has been proposed to be involved in cartilage and bone repair in arthritis, this pathway may be equally important in modulating FLS cell populations in inflamed synovium.

The mini vent technique: a simple method to facilitate accurate secondary portal placement in shoulder arthroscopy

Accurate portal placement is crucial in diagnostic and therapeutic shoulder arthroscopy. However, knowledge of anatomy and surgical principles may not be enough. Placement of a second portal is often hindered by a small amount of bleeding. Our technique easily rectifies this frequent problem by using a simple mini-vent.

Ankle arthroscopy in the lateral decubitus position.

Ankle or subtalar arthroscopy is a commonly performed procedure. It is often desirable to perform a diagnostic or therapeutic ankle arthroscopy followed by an open lateral ankle or hindfoot surgery. Standard positioning for ankle or subtalar arthroscopy is supine with or without the use of noninvasive distractor. In order to save operative time and avoid repositioning and redraping the patient intraoperatively, the authors have developed a positioning technique for performing ankle or subtalar arthroscopy, as well as anterior or medial procedures, followed by sequential procedures of the lateral ankle or hindfoot.

Localized pigmented villonodular synovitis of the knee: diagnostic challenge and arthroscopic treatment: a report of three cases

The localized form of pigmented villonodular synovitis (LPVS) is a lesion characterized by focal involvement of the synovial membrane. The knee is the most commonly affected joint. We report three cases of LPVS of the knee which were not diagnosed upon clinical evaluation. The aim is to bring the attention of clinicians to this pathological entity, which is often regarded as extremely rare and is therefore not considered in the early differential diagnosis of various knee derangements. Diagnostic and therapeutic arthroscopy was performed. The lesions were completely resected and patohistological findings confirmed the diagnosis of LPVS. All of our three patients have remained asymptomatic at 8, 10, and 12-month follow-ups.

Arthroscopy

Canine arthroscopy has made significant technological and scientific advancements in the last 10 years. The history of canine arthroscopy and currently available equipment required for performing diagnostic and therapeutic arthroscopy are discussed. Basic arthroscopic techniques are described in detail. Specific approaches to the major joints and associated disease processes treatable by arthroscopic methods are reviewed. The future of canine arthroscopy is bright and specific procedures for treating the joint diseases of dogs will undoubtedly be described as the collective arthroscopic expertise of veterinary surgeons increases.

Subtalar joint arthroscopy for sinus tarsi syndrome: A review of 29 cases

Twenty-nine consecutive patients who underwent diagnostic or therapeutic subtalar joint arthroscopy for sinus tarsi syndrome were retrospectively reviewed. The mean length of follow-up was 18 months. There was a history of trauma in 86% of the patients, with an inversion sprain being the most common predisposing injury (63%). All patients had a primary preoperative diagnosis of sinus tarsi syndrome. Magnetic resonance imaging was useful in identifying subtalar joint chronic synovitis and/or fibrosis in all 26 patients who were imaged. Subtalar joint synovectomy was the most common procedure performed. Twelve patients had 15 additional operative procedures. One patient required an arthrotomy secondary to arthrofibrosis. There were no postoperative complications. The mean return to full activity was 4 months. The mean postoperative AOFAS Ankle-Hindfoot Scale score was 85 points. Subtalar joint arthroscopy has proven to be a relatively safe and effective diagnostic and therapeutic technique in the management of sinus tarsi syndrome.

Regional techniques for day surgery: Intraarticular anesthesia and analgesia

Diagnostic and therapeutic (surgical) arthroscopy has become a standard procedure because of its accuracy and short period of time for postoperative rehabilitation. Its practice under local (periarticular) and/or intraarticular anesthesia simplify the procedure and decrease the costs for the hospital, allowing its practice in ambulatory patients. Arthroscopy has been applied in knee and shoulder joints, but progressively is used for arthroscopic surgery of the wrist, ankle, and in certain pathologies of metatarsophalangeal and the temporomandibular joint. The purpose of this report is twofold: To present the technique used by the authors in the approaches performed by them. Then to present a wide analysis of the experience accumulated in the application of the periarticular and intraarticular anesthesia in the practice of diagnostic and surgical arthroscopy, presenting drugs of choice and the rationale for combinations Copyright © 2000 by W.B. Saunders Company

Case Report Localized pigmented villonodular synovitis of the knee: arthroscopic treatment

Pigmented villonodular synovitis (PVNS) is a relatively rare condition. It occurs in two forms: a diffuse form involves the entire synovium and occurs in the majority of cases, and a localized form involves a discrete section of the synovium. The disorder almost always involves a single joint and the knee is most commonly affected. We report on three cases of localized PVNS that involved the patellar fat pad and synovium. Diagnostic and therapeutic arthroscopies were performed, and typical localized PVNS was found. Complete resection of the lesions was performed arthroscopically. Arthroscopy can be used as an effective diagnostic and therapeutic tool for identification and treatment of intra-articular localized PVNS of the knee.Arthroscopy 1998 Oct;14(7):764-8

Analgesic effects of intra-articular morphine during and after knee arthroscopy: a comparison of two methods

The objective of this study was to compare the analgesic effects of intra-articularly administered bupivacaine with bupivacaine/morphine during and after therapeutic knee arthroscopy. In a prospective, randomized study, 50 patients with clinical signs of medial meniscal injury were allocated to two groups, A and B. The patients in group A received 40 mL of 0.25% bupivacaine while the same dose of bupivacaine combined with 1 mg of morphine sulphate was administered in group B. Pain was estimated using the visual analogue scale (VAS) during surgery and at 2, 4, 6, and 24 hours after the operation was completed. Supplementary analgesic requirements were also registered, as well as the patients' overall rating of the entire procedure. The pain scores were significantly lower in Group B throughout the whole postoperative observation period. However, no significant differences were found between the two groups in terms of intraoperative pain scores, supplementary analgesic requirements, or the overall rating of the procedure. This study provides evidence that arthroscopic surgery can be performed in a safe manner after intra-articularly administered bupivacaine with or without low-dose morphine. The combination of low- dose morphine and bupivacaine did, however, produce a superior postoperative analgesic effect during the 24 hours following knee arthroscopy compared with bupivacaine alone. Arthroscopy 1998 Mar;14(2):192-6

Clinical results of therapeutic temporomandibular joint arthroscopy: A prospective study of 34 arthroscopies with prediscal section and retrodiscal coagulation: Chossegros C, Cheynet F, Gola R, et al. Br J Oral Max Surg 34:504, 1996

Clinical results of therapeutic temporomandibular joint arthroscopy: A prospective study of 34 arthroscopies with prediscal section and retrodiscal coagulation: Chossegros C, Cheynet F, Gola R, et al. Br J Oral Max Surg 34:504, 1996

Clinical results of therapeutic temporomandibular joint arthroscopy: A prospective study of 34 arthroscopies with prediscal section and retrodiscal coagulation: Chossegros C, Cheynet F, Gola R, et al. Brit J Oral Maxillofac Surg 34:504, 1996

Clinical results of therapeutic temporomandibular joint arthroscopy: A prospective study of 34 arthroscopies with prediscal section and retrodiscal coagulation: Chossegros C, Cheynet F, Gola R, et al. Brit J Oral Maxillofac Surg 34:504, 1996

MRI can prevent unnecessary arthroscopy.

We compared the practice of four orthopaedic consultants as regards the use of MRI and arthroscopy to diagnose problems of the knee. In one year 324 arthroscopies and 66 MR scans were performed for this purpose. We found that MRI is a reliable and cheaper alternative to 'diagnostic arthroscopy'. We consider that patients with definite clinical signs merit an early 'therapeutic arthroscopy', but that all other knees should be investigated by MRI. This policy spares patients from unnecessary and expensive surgery. Arthroscopy for diagnostic purposes should be used only with a specific purpose. Modern MRI can and should replace "having a look".

MRI CAN PREVENT UNNECESSARY ARTHROSCOPY

We compared the practice of four orthopaedic consultants as regards the use of MRI and arthroscopy to diagnose problems of the knee. In one year 324 arthroscopies and 66 MR scans were performed for this purpose. We found that MRI is a reliable and cheaper alternative to ‘diagnostic arthroscopy’. We consider that patients with definite clinical signs merit an early ‘therapeutic arthroscopy’, but that all other knees should be investigated by MRI. This policy spares patients from unnecessary and expensive surgery. Arthroscopy for diagnostic purposes should be used only with a specific purpose. Modern MRI can and should replace “having a look”.

Arthroscopy of the knee in children

The diagnosis of disorders of the knee in children is known to be difficult. Indications of the diagnostic and therapeutic arthroscopy should be carefully evaluated in the childhood period. Arthroscopy was performed in 47 knees of 47 children in our department between the years of June 1985 September 1997. Children were aged 1,5 to 15 years, mean age being 13, 2 years. There were 18 females (38%) and 29 males (62%). Arthroscopic surgical proccedures were carried out due to meniscal and ligamentous lesions (in 17 patients, aged 4-15, mean age 12. 9 years), diagnostic and biopsy for sinovial and intraarticular tumoral lesions (in 17 patients, aged 1.5-15. Mean age 9,8 years), septic arthritis (in 6 patients, aged 4-13, mean age 8.4 years) and anterior knee pain which were refractory to the conservative treatment and chondral lesions (in 7 patients, aged 5-15, mean age 12.3 years). The arthroscopic findings did not always support the clinical diagnosis in meniscal lesions, only 41% of meniscal tears were suspected preoperatively. This study also indicated that in preadolecents, only 60% of preoperative clinical diagnosis were confirmed at surgery. According to results of the histopathology of arthroscopic biopsy materials, there were 6 pigmented villonodular sinovitis, 1 tuberculosis arthritis, 1 osteomyelitis and 2 JRA. We determined symptomatic medial plicae at 6 knees. It is concluded that arthroscopy of the knee in children especially in meniscal lesions and septic arthritis is a safe procedure with high diagnostic and therapeutic value.

Clinical results of therapeutic temporomandibular joint arthroscopy: a prospective study of 34 arthroscopies with prediscal section and retrodiscal coagulation

Thirty-four therapeutic temporomandibular arthroscopies were done during a 24-month period for patients with debilitating joint disorders (mainly disc displacements with or without reduction) who had not responded to non-invasive treatment. Lysis and lavage with prediscal section and retrodiscal coagulation were the techniques used. Analysis of the results indicated subjective improvement of pain in 71% of cases, noise in 78%, jaw opening in 88% and diet in 97% and objective evidence of disappearance of noise in 29% and improvement of jaw opening in 94% (mean 9.24 mm). In jaw opening, improvement was highly significant, compared with the preoperative results, P < 0.01. We conclude that temporomandibular arthroscopy is safe and indicated in disc displacements and joint luxation if medical treatment has failed.

Magnetic Resonance Imaging of the Musculoskeletal System

Since its introduction to musculoskeletal imaging in the early 1980s, magnetic resonance imaging has proven to be an excellent technique for evaluating patients with knee problems. Studies have shown it to be accurate in the identification of abnormalities of the menisci, ligaments, patellofemoral joints, and other soft tissue and osseous structures in the knee. The main advantages of magnetic resonance imaging are its noninvasive nature and its high accuracy and negative predictive value in evaluating the menisci and anterior cruciate ligament. Magnetic resonance imaging has been shown to be useful in the detection and diagnosis of various traumatic and nontraumatic knee abnormalities. It has also proved useful in the diagnosis of occult or unsuspected bone lesions. Magnetic resonance imaging can therefore help in the selection of those patients who need therapeutic arthroscopy. There is evidence that magnetic resonance imaging of the knee is a cost effective screening technique when used in conjunction with the clinical findings in patients who are candidates for arthroscopy. Magnetic resonance imaging of the knee is still a relatively expensive modality.