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Zusammenfassung Operationsziel Offene Therapie osteochondraler Läsionen des Kniegelenks zur vollständigen Auffüllung knöcherner Defekte und Wiederherstellung der Gelenkfläche. Indikationen Fokale, symptomatische osteochondrale Defekte des Kniegelenks ab einer Knochendefekttiefe von ≥ 5 mm und Größe von ≥ 1,5 cm2. Kontraindikationen Arthrose (> KL Grad 2), „kissing lesions“ (ICRS > Grad 2), Alter > 50 Jahre, unbehandelte Bandinstabilitäten oder Beinachsenfehstellungen zum Nachteil des betroffenen Gelenkkompartiments, fehlendes Defektcontainment, entzündliche Gelenkerkrankungen. Operationstechnik Zweizeitiger Eingriff: Ersteingriff (arthroskopische Knorpelprobenentnahme): Defektevaluierung, Entnahme von Knorpelstücken für die Chondrozytenkultivierung, bei Bedarf Behandlung von Begleitpathologien. Zweiteingriff (offene Defektbehandlung): Arthrotomie, Präparation des knöchernen Defekts, Auffüllung mit autologen Spongiosazylindern aus dem Beckenkamm, Knorpeldefektpräparation (kann größer als knöcherner Defekt sein) und matrixgestützte autologe Chondrozytentransplantation. Weiterbehandlung Ersteingriff: frühfunktionelle Nachbehandlung mit schmerzorientierter Vollbelastung je nach Begleiteingriffen. Zweiteingriff: keine Drainage, funktionelle Kniegelenkorthese in Streckstellung für 1 Woche, danach schrittweise Freigabe der Flexion, Teilbelastung für 6 Wochen, Motorschiene (CPM) ab dem 1. postoperativen Tag. Ergebnisse Seit 2018 sind 8 Patienten (mittleres Alter 29,4 Jahre, Spanne 18 bis 36) mit der beschriebenen Technik behandelt worden. Alle Patienten konnten nach durchschnittlich 12 Monaten nachuntersucht werden. Der Gesamt-KOOS (Knee injury and Osteoarthritis Outcome Score) verbesserte sich im Mittel von 45,8 auf 81,3, und die postoperativen radiologischen Kontrollen zeigten die Einheilung der Spongiosazylinder bei allen Patienten. Der MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) Score ergab 80,4 Punkte.

In most cases, a standard access via a medial parapatellar arthrotomy with a carefully performed release technique is sufficient for a good exposure of the knee joint in the revision situation. Crucial steps are targeted scar removal, sufficient soft tissue release and recreation of the shifting layers. Tuberosity osteotomy is an effective option for extended exposure at the distal joint region, facilitating a patella replacement to correct abnormalities in the patellofemoral joint. Extended exposure to the proximal joint is possible with the rectus snip and the VY plasty technique. Due to the rather poor results, a quadriceps turndown should be seen more historically and should no longer be used. In extreme cases, a femoral peel or an osteotomy of the medial epicondyle can help achieve the reconstruction of a joint. The latter techniques are reserved for selected cases and always require a linked implant.

To evaluate the efficacy of arthrotomy, when compared with arthroscopy, in the treatment of adults with septic arthritis of any joint. MEDLINE, EMBASE, and Scopus were searched to identify studies comparing arthrotomy and arthroscopy as therapeutic approaches in patients with septic arthritis of any joint. The main outcome was the re-infection rate. A meta-analysis was performed using the generic inverse variance method with random or fixed effects model depending on heterogeneity between studies. Heterogeneity was tested with the I2 statistic index. Twenty studies with 10,249 patients treated by arthrotomy or arthroscopy were evaluated. We observed a significant lower risk of re-infection (odds ratio [OR], 1.35 [95% CI, 1.16–1.58]; p = 0.0002) and complications (OR, 1.32 [95% CI, 1.12–1.55]; p = 0.001) rate as well as less hospital stay (mean difference [MD], 0.57 days [95% CI, 0.10–1.05]; p = 0.02) favouring arthroscopic intervention. The subanalysis indicated that patients with knee (OR, 1.50 [95% CI, 1.17–1.92]; p = 0.001) and shoulder (OR, 1.24 [95% CI, 1.00–1.53]; p = 0.04) septic arthritis intervened by arthrotomy had a higher risk of re-infection. A lower number of hospitalization days (MD, 0.89 days [95% CI, 0.31–1.47]; p = 0.003) and a lower risk for complications (OR, 1.26 [95% CI, 1.04–1.52]; p = 0.02) were observed in patients treated with arthroscopy after septic knee arthritis. Available evidence suggests that patients with septic arthritis of the knee and shoulder treated by arthroscopy have less risk of re-infection than those treated by arthrotomy. The quality of the body of evidence is still insufficient to reach reliable conclusions. CRD42020176044. Date registration: April 28, 2020.

Treatment of tricompartimental osteoarthritis (OA) using customized instruments and implants for cruciate-retaining total knee arthroplasty. Use of patient-specific instruments and implants (ConforMIS iTotalSymptomatic tricompartmental OA of the knee (Kellgren-Lawrence stage IV) with preserved posterior cruciate ligament (PCL) after unsuccessful conservative or joint-preserving surgical treatment.Knee ligament instabilities of the posterior cruciate or collateral ligaments. Infection. Relative contraindication: knee deformities15° (varus, valgus, flexion); prior partial knee replacement.Midline or parapatellar medial skin incision, medial arthrotomy; distal femoral resection with patient-specific cutting block; tibial resection using either a cutting jig for the anatomic slope or a fixed 5° slope. Balancing the knee in extension and flexion gap using patient-specific spacer. The final tibial preparation achieved with gap-balanced placement of the femoral cutting jigs. Kinematic testing using anatomic trial components. Final implant components are cemented in extension. Wound layers are sutured. Drainage is optional.Sterile wound dressing; compressive bandage. No limitation of the active and passive range of motion. Optional partial weight bearing during the first 2 weeks, then transition to full weight bearing. Follow-up directly after surgery, at 12 and 52 weeks, then every 1-2 years.Overall 60 patients with tricompartmental knee OA and preserved PCL were treated. Mean age was 66 (range 45-76) years. Minimum follow-up was 12 months. There was 1 septic revision after a low-grade infection, 1 reoperation to replace the patellar due to patellar osteoarthritis and 3 manipulations under anesthesia (MUAs) to increase range of motion. Radiographic analyses demonstrated an ideal implant fit with less than 2 mm subsidence or overhang. The WOMAC score improved from 154.8 points preoperatively to 83.5 points at 1 year and 59.3 points at 2 years postoperatively. The EuroQol-5D Score also improved from 11.1 points preoperatively to 7.7 points at 1 year postoperatively.ZIEL: Kreuzbanderhaltende Knietotalendoprothese bei Patienten mit Pangonarthrose mittels medialer Arthrotomie. Verwendung patientenspezifischer Instrumente und Implantate (ConforMIS iTotalSymptomatische Pangonarthrose (nach Kellgren und Lawrence Stadium IV) mit erhaltenem hinterem Kreuzband (HKB) nach erfolgloser konservativer und/oder operativer gelenkerhaltender Therapie.Kniebandinstabilitäten des hinteren Kreuzbands oder der Seitenbänder. Infektion. Relative Kontraindikation: Kniedeformitäten15° (Varus, Valgus, Streckdefizit) und/oder vorangegangener Teilgelenkersatz.Mittige oder medial parapatellare Hautinzision, mediale Arthrotomie. Distale femorale Resektion mit patientenspezifischem Schneideblock; Tibiaresektion mit einem Schneideblock, der einen anatomischen oder einen fixen tibialen Slope von 5° enthält. Balancierung des Kniegelenks in Streckung und Beugung mit individuell angepassten Balancierungshilfen. Finale balancierte Femurpräparation mit individuellen femoralen Schneideblöcken. Kinematische Prüfung mit anatomischen Probekomponenten. Die abschließende Tibiapräparation erfolgt mittels individueller Bohrschablone. Die finalen Implantatkomponenten werden in Streckstellung einzementiert. Schichtweiser Wundverschluss. Die Einlage einer Drainage ist optional.Sterile Wundauflagen und elastokompressive Wickelung. Keine Limitierung des aktiven und passiven Bewegungsausmaßes. Eine Teilbelastung für die ersten 2 Wochen postoperativ ist optional, bevor der Übergang zur Vollbelastung erfolgt. Verlaufskontrollen direkt postoperativ, nach 12 und 52 Wochen, danach alle 1 bis 2 Jahre.Behandelt wurden 60 Patienten mit Pangonarthrose und erhaltenem HKB. Durchschnittsalter: 66 (45–76) Jahre. Nachuntersuchungszeit mindestens 12 Monate. Es gab eine Revision nach einer Low-grade-Infektion, eine Reoperation zur Behandlung einer Retropatellararthrose mit Retropatellarersatz und 3 Narkosemobilisationen zur Verbesserung der Beweglichkeit. Röntgenkontrollen zeigten durchweg eine ideale Implantatpassform mit weniger als 2 mm Implantatüber- oder -unterstand. Der WOMAC-Gesamtscore verbesserte sich von 154,8 Punkten präoperativ auf 83,5 Punkte nach einem Jahr und auf 59,3 Punkte nach 2 Jahren postoperativ. Auch der EuroQol-5D-Score verbesserte sich von 11,1 Punkten präoperativ auf 7,7 Punkte postoperativ.

To quantify propagation of small longitudinal tears in the lateral meniscus in ACL intact and deficient knees. Using a robotic testing system, 5-Nm of external tibial torque + 5-Nm of valgus torque + 250-N of axial compression was applied to 14 fresh-frozen cadaveric knees while the knees were flexed from 30° to 90°. Knees were divided into two groups: intact (N = 8) and ACL deficient (N = 6). Kinematic data was recorded for four knee states: intact or ACL deficient knee, after posterior arthrotomy, meniscus tear at baseline, and after 500 cycles of the applied loading condition. Lateral meniscus tear length increased throughout the 500 cycles regardless of the ACL integrity (p

Septic arthritis (SA) is an emergency orthopedic condition that carries significant patient morbidity and mortality. Clinical data and blood test analyses are fairly unreliable in making the diagnosis and, therefore, utilizing a feasible and reliable diagnostic tool is desirable, particularly in emergency settings where rapid diagnosis is pivotal. Here, we report the case of a 58-year-old male presenting to the emergency department with a swollen elbow. After demonstration of a large articular effusion with point-of-care ultrasound, the synovial fluid analysis was compatible with SA. The patient was treated with elbow arthrotomy and systemic antibiotics and discharged shortly thereafter, uneventfully. Finally, we discuss the impact of ultrasound in diagnosing SA and the many advantages that make it the first-line tool in urgent care. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s40477-020-00506-2) contains supplementary material, which is available to authorized users.

Restoring stability after total knee arthroplasty (TKA) and improving joint function using a cemented rotating hinge system. Ligament instability and/or osseous defects (including Anderson Orthopaedic Research Institute [AORI] classification type II defects) after primary TKA or TKA revision surgery. Distal femoral or proximal tibial bowing requiring implant systems that provide femoral or tibial offset stems. Persistent periprosthetic infection. Poor therapeutic compliance. AORI type III defects. Medial arthrotomy. Femoral and tibial component removal with small saw blades and chisels. Intramedullary alignment for the tibial and femoral cuts. Debridement and removal of membranes and cement remnants. Reconstruction of joint line and correct TKA alignment. Trial reduction. Cement fixation. Unrestricted range of motion, partial weight bearing for 4 weeks. Between 2012 and 2013, 18 patients suffering from ligament insufficiency after TKA were revised using the described system and included in a prospective study protocol. The mean follow-up was 37 months (range 30–46 months). There was a significant improvement of the Oxford Knee Score (OKS) from 19 (range 7–29) preoperatively to 29 (range 10–45) postoperatively (p = 0.004). The Knee Society Score (KSS) knee assessment subscore improved from 35 (range 9–70) to 67 (range 35–97) (p = 0.002) and the pain score from 7 (range 0–50) to 24 (range 0–50) (p = 0.008).

The broad aim of this study was to compare the safety and efficacy of using barbed sutures versus standard-of-care sutures for closure of arthrotomy during total knee arthroplasty. Specifically, we compared the duration of arthrotomy closure, the number of sutures utilized for arthrotomy closure, and 90-day outcomes, including wound-related readmission, reoperation, and complications. A total of 60 patients undergoing primary total knee arthroplasty were enrolled in a prospective, blinded trial and randomized to receive either running closure of the arthrotomy with barbed sutures (n = 30) or interrupted closure with standard-of-care sutures (n = 30). Arthrotomy closure time was significantly shorter in the barbed suture group (3 min ± 2 min) versus the standard-of-care group (13 min ± 5 min, p

Background Matrix-induced autologous chondrocyte implantation (mACI) can be performed in a full arthroscopic or mini-open fashion. A systematic review was conducted to investigate whether arthroscopy provides better surgical outcomes compared with the mini-open approach for mACI in the knee at midterm follow-up. Methods This systematic review was conducted following the PRISMA guidelines. The literature search was performed in May 2021. All the prospective studies reporting outcomes after mACI chondral defects of the knee were accessed. Only studies that clearly stated the surgical approach (arthroscopic or mini-open) were included. Only studies reporting a follow-up longer than 12 months were eligible. Studies reporting data from combined surgeries were not eligible, nor were those combining mACI with less committed cells (e.g., mesenchymal stem cells). Results Sixteen studies were included, and 770 patients were retrieved: 421 in the arthroscopy group, 349 in the mini-open. The mean follow-up was 44.3 (12–60) months. No difference between the two groups was found in terms of mean duration of symptoms, age, body mass index (BMI), gender, defect size (P > 0.1). No difference was found in terms of Tegner Score (P = 0.3), Lysholm Score (P = 0.2), and International Knee Documentation Committee (IKDC) Score (P = 0.1). No difference was found in the rate of failures (P = 0.2) and revisions (P = 0.06). Conclusion Arthroscopy and mini-arthrotomy approaches for mACI in knee achieve similar outcomes at midterm follow-up. Level of evidence II, systematic review of prospective studies.

The correct choice of a fracture-specific surgical approach with an articular accessibility in complex tibial plateau fractures to facilitate durable fracture fixation of the anatomic articular reconstruction is under debate, as the most important risk factor for malreduction in complex tibial plateau fractures is an impaired visualization of the articular surface. Six established surgical approaches were simulated on 12 cadaver knees. The visible articular surface was labeled with an electrocautery device for each approach and subsequently analyzed with ImageJ. Areas of each hemiplateau were compared using the Student’s t test. In the lateral tibial plateau, the dorsal 19.0 ± 5.8% of the articular surface could be exposed via the postero-lateral approach. Via the antero-lateral arthrotomy, 36.6 ± 9.4% of the anterior articular surface was visible. The additional osteotomy of the lateral femoral epicondyle significantly increased the exposure to 65.6 ± 7.7% (p

Septic arthritis of the knee is an orthopaedic emergency that is associated with marked morbidity and can potentially be life threatening. Surgical debridement can be performed either arthroscopically or via an arthrotomy. The aim of this study was to compare the 30-day complications and adverse outcomes between the two procedures.Patients with a diagnosis of septic arthritis of the knee between 2011 and 2015 were identified using the ACS-NSQIP database. The study population included 695 patients, who had knee septic arthritis and underwent either an arthroscopic irrigation or debridement (ID) (n = 464) or open irrigation and debridement (n = 231). Preoperative data included demographics, independent functional status, and comorbidities. Outcomes of interest included wound complications, infectious complications, cardiovascular events, hospital readmissions, and reoperations, or any of the previous adverse events.Both cohorts were similar in most baseline characteristics. Bleeding requiring transfusion was significantly lower in the arthroscopic (n = 13; 3.6%) compared to the open procedure (n = 31; 13.4%; p = 0.0001). Home discharge was significantly higher in the arthroscopic irrigation and debridement group (n = 310; 67.5%) compared to the open group (n = 126; 55%; p = 0.0013). The overall incidence of adverse events was lower in the arthroscopic group (n = 158; 34%) compared to the open group (n = 112; 49%; p = 0.0002). There was no difference in rates of infectious complications, thromboembolic events, hospital readmission, reoperation, or mortality between the groups. Open irrigation and debridement was associated with higher risk of bleeding requiring transfusion (OR = 3.79; 95% CI: 2.02-7.13; p = 0.0001), higher risk of incidence of adverse events (OR = 1.46; 95% CI: 1.02-2.08; p = 0.039), and lower home discharge (OR = 3.79; 95% CI: 2.02-7.13; p = 0.0001) within 30 days after the procedure.Arthroscopic irrigation and debridement demonstrated favourable short-term outcomes. Patients who underwent arthroscopic irrigation and debridement had lower rates of blood transfusions, lower rates of adverse events, and higher home discharge rates compared to open irrigation and debridement. This study is the largest analysis comparing arthroscopic vs. open irrigation and debridement in a national database sample. These findings conclude that arthroscopic debridement can be an alternative first-line option in managing septic arthritis.III.

Background Surgical site infections (SSI) are associated with increased morbidity and mortality. To lower the incidence of SSI, antimicrobial prophylaxis is given 30–60 min before certain types of surgeries in both human and veterinary patients. However, due to the increasing concern of antimicrobial resistance, the benefit of antimicrobial prophylaxis in clean orthopaedic and neurosurgeries warrants investigation. The aims of this retrospective cross-sectional study were to review the rate of SSI and evaluate the compliance with antimicrobial guidelines in dogs at a veterinary teaching hospital in 2012–2016. In addition, possible risk factors for SSI were assessed. Results Nearly all dogs (377/406; 92.9%) received antimicrobial prophylaxis. Twenty-nine dogs (7.1%) did not receive any antimicrobials and only four (1.1%) received postoperative antimicrobials. The compliance with in-house and national protocols was excellent regarding the choice of prophylactic antimicrobial (cefazolin), but there was room for improvement in the timing of prophylaxis administration. Follow-up data was available for 89.4% (363/406) of the dogs. Mean follow-up time was 464 days (range: 3–2600 days). The overall SSI rate was 6.3%: in orthopaedic surgeries it was 6.7%, and in neurosurgeries it was 4.2%. The lowest SSI rates (0%) were seen in extracapsular repair of cranial cruciate ligament rupture, ulnar ostectomy, femoral head and neck excision, arthrotomy and coxofemoral luxation repair. The highest SSI rate (25.0%) was seen in arthrodesis. Omission of antimicrobials did not increase the risk for SSI (P = 0.56; OR 1.7; CI95% 0.4–5.0). Several risk factors for SSI were identified, including methicillin-resistant Staphylococcus pseudintermedius carriage (P = 0.02; OR 9.0; CI95% 1.4–57.9) and higher body temperature (P = 0.03; OR 1.69; CI95% 1.0–2.7; mean difference + 0.4 °C compared to dogs without SSI). Conclusions Antimicrobial prophylaxis without postoperative antimicrobials is sufficient to maintain the overall rate of SSI at a level similar to published data in canine clean orthopedic and neurosurgeries.

Purpose This study was performed to determine whether periarticular injection performed in the early stage of total knee arthroplasty (TKA) could provide a better postoperative pain relief than periarticular injection performed in the late stage of TKA. The hypothesis was based on the concept that analgesic intervention before the onset of noxious stimuli would be associated with less postoperative pain. Methods A total of 105 participants were randomly assigned to receive superficial injection just prior to arthrotomy (early stage periarticular injection group) or superficial injection after implanting the prosthesis (late-stage periarticular injection group) in patients undergoing unilateral TKA with 1:1 treatment allocation. In both groups, deep injection was performed according to the same schedule (just prior to implanting prosthesis). The solution consisted of 300 mg of ropivacaine, 8 mg of morphine, 40 mg of methylprednisolone, 50 mg of ketoprofen, and 0.3 mg of epinephrine mixed with normal saline to a final volume of 60 mL. All surgeries were managed under general anesthesia without any regional blocks. Registry-specified primary outcome was postoperative pain score at rest measured at the recovery room using a 100-mm visual analog scale (VAS). The VAS score was compared between two groups and assessed to reach the reported threshold values for the minimal clinically important difference (MCID) of 10 mm for the postoperative VAS score. Results The VAS score at the recovery room was significantly lower in the early stage periarticular injection group than the late-stage periarticular injection group (23 ± 25 mm versus 39 ± 34 mm, respectively; 95% confidence interval 4–28 mm; p = 0.0078). The mean difference in the primary outcome fulfilled the MCID value. Conclusions Bringing forward the timing of periarticular injection may provide significant and clinically meaningful improvement in pain following TKA under general anesthesia. Level of evidence I.

This trial was conducted to determine the medium-term functional outcome of displaced tibial plateau fracture patients treated with closed fluoroscopic assisted reduction and internal fixation (CRIF) versus patients treated with standard open reduction with sub-meniscal arthrotomy and internal fixation (ORIF). A prospective trial was conducted in adult patients with displaced AO/OTA 41 B and 41 C tibial plateau fractures. Patients were assigned to treatment based upon the standard treatment of the surgeon involved following the call schedule for the day, either CRIF or ORIF. Postoperative radiographs and CT were performed on all patients and patients were followed for a minimum of 2 years. Primary outcome measures were the KOOS, SMFA and SF-36. Seventy patients were recruited with 2 year follow-up on 35 patients in the CRIF group and 27 patients in the ORIF group. Postoperative CT scans showed that reductions were better with the ORIF group especially in the posterolateral quadrant as compared to the CRIF group. The frequency of mal-reductions was higher in the CRIF group. The KOOS, at two years, showed that the CRIF had significantly less good outcomes in the subcategories of SPORT (p = 0.03) and QOL (p = 0.01) measurements. ORIF with a sub-meniscal arthrotomy provides better quality reductions and better medium-term results as compared to CRIF for tibial plateau fractures. This may provide more long-term benefit from osteoarthritic symptoms in this patient group. Therapeutic, Level 2.

Functional outcomes, such as joint flexion and gait, are important indicators of efficacy in musculoskeletal research. Current technologies that objectively assess these parameters, including visual tracking systems and force plates, are challenging to deploy in long-term translational and clinical studies. To that end, we developed a wearable device that measures both physical activity and joint flexion using a single integrated sensor and magnet system, and hypothesized that it could evaluate post-operative functional recovery in an unsupervised setting. To demonstrate the feasibility of measuring joint flexion, we first compared knee motion from the wearable device to that acquired from a motion capture system to confirm that knee flexion measurements during normal human gait, predicted via changes in magnetic field strength, closely correlated with data acquired by motion capture. Using this system, we then monitored a porcine cohort after bilateral stifle arthrotomy to investigate longitudinal changes in physical activity and joint flexion. We found that unsupervised activity declined immediately after surgery, with a return to pre-operative activity occurring over a period of 2 weeks. By providing objective, individualized data on locomotion and joint function, this magnet-based system will facilitate the in vivo assessment of novel therapeutics in translational orthopaedic research.

Purpose: Snapping annular ligament is an uncommon cause of lateral elbow pain. The purpose of this case series was to evaluate the clinical presentation and surgical outcomes for snapping annular ligament. Methods: Included were 23 patients with snapping annular ligament who received surgical treatment between 2007 and 2016. There were two treatment groups with either resection (arthroscopic or open procedure, n = 15) or open annular ligament reconstruction (n = 8). Patients were assessed with the Mayo Elbow Performance Index and the Oxford Elbow Score. Preoperative and postoperative scores were compared with a paired t test. Results: Pain was located laterally in nine patients (39.1%), anteriorly in three patients (13.0%), anterolaterally in two patients (8.7%), and diffusely in nine patients (39.1%). In total, 16 patients (69.6%) experienced a snapping sensation and ten patients (43.5%) locking of the elbow. According to the patients’ reported outcomes, their symptoms improved significantly after both procedures. Conclusions: This is the largest case series in the literature on snapping annular ligament, an uncommon cause of lateral elbow pain. Good treatment results are expected with resection of the interpositioned part of the annular ligament or annular ligament reconstruction. Level of evidence: IV.

To determine the clinical and radiographic efficacy of chitosan-glycerol phosphate/blood implant versus hyaluronic acid-based cell-free scaffold in patients with focal osteochondral lesion of the knee joint. Clinical data of 46 patients surgically treated using either chitosan-glycerol phosphate/blood implant (25 patients, Group 1) or hyaluronic acid-based cell-free scaffold (21 patients, Group 2) in combination with microfracture were retrospectively evaluated. All lesions were Outerbridge grade III or IV with a mean lesion size of 3.3 ± 0.7 cm2. The mean follow-up time was 24.4 months. Visual analogue scale (VAS), Lysholm knee score, and Tegner activity scale were the instruments to evaluate the clinical status. Magnetic resonance observation of cartilage repair tissue (MOCART) system was used to analyze the characteristics of repair tissue. No significant differences were detected between the groups regarding VAS, Lysholm, and Tegner scores at any time interval during the whole follow-up. The mean post-operative VAS and Lysholm scores at the latest follow-up was significantly better in cases with the lesion size ≤ 3 cm2 in Group 1 (p = 0.001, p

Prosthetic joint infection is one the most common causes of revision surgery after hip or knee replacement. Debridement and implant retention (DAIR) is one method of treating these infections; however, significant controversy exists. The purpose of our review was to describe current knowledge about indications, intraoperative/postoperative patient management, and outcomes of DAIR. Patient selection affects the success of DAIR. Medical comorbidities, duration of symptoms, and nature of infectious organism all influence outcomes. Intraoperative techniques such as open arthrotomy, extensive debridement, copious irrigation, and exchange of modular parts remain current standards for DAIR. Postoperative administration of antibiotics tailored to operative cultures remains critical. Antibiotic suppression may increase the success of DAIR. DAIR provides reasonable infection eradication between 50 and 80% with improved outcomes in appropriately selected patients. More research is needed on the use of adjuvant therapies intraoperatively and the role of postoperative antibiotic suppression.

The medial parapatellar arthrotomy (MPPA) is a commonly utilized surgical approach; however, the placement of the arthrotomy and its influence on intraoperative patellar tracking has not been evaluated. Six knees from three fresh frozen cadavers with transthoracic amputations were operated on. All underwent standard posterior stabilized total knee arthroplasty using a medial parapatellar approach placed at the border of the vastus medialis oblique (VMO)–quadriceps junction. Patellae were resurfaced in the standard fashion. All patellae tracked normally with the first arthrotomy placed at the junction of the VMO–quadriceps tendon using the “no touch” technique. Measurement of patellar lift-off from the implant surface of the medial aspect of the trochlea on the femoral component was made at 50°, 75°, and 90° of flexion and a merchant view radiograph taken to evaluate radiographic patellar tilt. To simulate a more lateral placement of the MPPA, a 5–6 mm slice of quadriceps tendon was then removed from the lateral aspect of the tendon from the patellar insertion to the most proximal portion of the arthrotomy. This simulated a 5–6 mm more lateral placement of the parapatellar arthrotomy. The same measurements and radiographs were taken as described previously. Two more times the same size slices was removed from the quadriceps tendon with subsequent measurements and radiographs obtained. The mean patellar lift-off with the first arthrotomy was 0 ± 0 mm for 50°, 75°, and 90° of flexion. The mean lift with the second arthrotomy was 2 ± 2, 3 ± 3, and 4 ± 3 mm respectively. The third arthrotomy had a mean patellar lift-off of 3 ± 2, 4 ± 3, and 8 ± 2 mm respectively, while the fourth arthrotomy had a mean lift-off of 6 ± 2, 8 ± 2, and 9 ± 4 mm. There was a significant correlation between percentage of quadriceps cut at 1 cm above the superior pole of the patella and patellar lift-off at 50° (R 2 = 0.70; p

The arthrotomy techniques of knee surgery may cause varying degrees of disruption to the tissue blood supply. The aim of this study was to investigate the effects of the medial parapatellar (MPPa), midvastus (MVa), subvastus (SVa) and lateral parapatellar (LPPa) approaches on regional tissue perfusion of the knee. In this experimental study, a total of 28 female rabbits were applied with four different arthrotomy techniques as Group MPPa, Group MVa, Group SVa and Group LPPa. The blood supply of the tissue around the knee was examined by scintigraphic imaging including the perfusion reserve and T max, and biochemical alteration of the oxidative stress parameters including malondialdehyde (MDA), fluorescent oxidation products (FlOPs), and histopathological findings were evaluated on tissue samples after 3 weeks. The perfusion reserve was increased in all four groups compared to the healthy, contralateral knees. In the Group LPPa, the vascularity was significantly increased compared to the Group MPPa (p = 0.006). In the examination of biochemical parameters, the increase in MDA levels was statistically significant in the Group MPPa compared with the Group LPPa (p = 0.004), and in the Group MVa compared with the Group LPPa (p = 0.006). The increase in the value of MDA levels was striking in the Group MPPa and Group MVa compared with the control group (p = 0.004, p = 0.004, respectively). The increase in another oxidative stress parameter, the tissue FlOPs levels, was statistically significant in the Group MPPa compared with the control group (p = 0.035). The LPPa and SVa caused less oxidative stress and less disruption of the muscle blood supply, in biochemical and scintigraphic parameters, compared to the MPPa and MVa. Therefore, in clinical practice, the SVa is preferable to the MPPa and MVa in total knee arthroplasty and the LPPa should be preferred more frequently in selected cases with critical soft tissue viability.

Intramedullary nail fixation remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point remains a crucial step in the surgical procedure. Tibial nailing using an infrapatellar starting point with the knee flexed over a radiolucent triangle has been established as a widely-used standard technique. Tibial nail insertion with the knee in the semi-extended position was introduced with the goal to counteract post-operative procurvatum deformities that frequently have been reported as a common problem in proximal third tibial shaft fractures. Early reports on tibial nailing in the semi-extended position used a knee arthrotomy in order to establish the proximal tibial starting point. Recent technological advances have provided the surgical community with instrumentation systems that allow for tibial nailing in the semi-extended position using a suprapatellar portal with nail insertion through the patellofemoral joint. Preliminary clinical studies have suggested favorable outcomes that can be achieved with this technique. This article provides a description of the surgical technique and a review of the currently available evidence.

Background Lateral flap numbness is a known side-effect of midline skin incision in total knee arthroplasty (TKA) and a cause of patient dissatisfaction. Anterolateral incision is an alternative approach which preserves the infrapatellar branches of the saphenous nerve and avoids numbness. Studies have compared both incisions, but in different patients. However, different patients may assess the same sensory deficit dissimilarly, because of individual variations in anatomy and healing responses. We compared the two incisions in the same patient at the same time, using an anterolateral incision on one knee and a midline incision on the other knee in simultaneous bilateral TKA. Other surgical steps including medial arthrotomy were idential. We also correlated subjective and objective findings. Materials and methods Twenty patients were prospectively randomized. Sensory loss and skin healing were assessed at 6, 12 and 52 weeks. Subjective preference for the knee with less numbness was charted on Wald’s Sequential Probability Ratio Test. Sensation scores for touch, vibration, static and moving two-point discrimination were measured. Scar healing was evaluated using the Patient and Observer Scar Assessment Scale (POSAS). Functional scores were measured. Results A statistically significant difference favoring knees with anterolateral incision was observed in patient preference at all assessment points and this correlated with sensation scores. A statistically significant difference was observed in POSAS score favoring knees with anterolateral incision at 6 and 12 weeks which became statistically insignificant at 1 year. Functional scores remained comparable. Conclusion We recommend anterolateral incision as a safe and effective method to circumvent the problem of lateral flap numbness with midline incision. Level of evidence I.

Bicompartmental knee replacement in patients with combined osteoarthritis (OA) of the medial or lateral and patellofemoral compartment. Patient-specific instruments and implants (ConforMIS iDuo™) with a planning protocol for optimal implant fit. Bicompartmental OA of the knee (Kellgren & Lawrence stage IV) affecting both the medial or lateral and patellofemoral compartment after unsuccessful conservative or joint-preserving surgery. Tricompartmental OA, knee ligament instabilities, knee deformities >15° (varus, valgus, extension deficit). Relative contraindication: body mass index >40; prior unicompartmental knee replacement or osteotomies. Midline or parapatellar medial skin incision, medial arthrotomy; identify mechanical contact zone of the intact femoral condyle (linea terminalis); remove remaining cartilage and all osteophytes that may interfere with the correct placement of the individually designed instruments. Balance knee in extension with patient-specific balancing chips. Resection of proximal tibia with an individual cutting block; confirm axial alignment using an extramedullary alignment guide, balance flexion gap using spacer blocks in 90° flexion. Final femur preparation with resection of the anterior trochlea. After balancing and identification of insert heights, final tibial preparation is performed. Implant is cemented in 45° of knee flexion. Remove excess cement and final irrigation, followed by closure. Sterile wound dressing; compressive bandage. No limitation of active/passive range of motion (ROM). Partial weight bearing the first 2 weeks, then transition to full weight bearing. Follow-up directly after surgery, at 12 and 52 weeks, then every 1–2 years. In all, 44 patients with bicompartmental OA of the medial and patellofemoral compartment were treated. Mean age 59 years. Minimum follow-up 12 months. Implant converted to TKA due to tibial loosening (1 patient); patella resurfacing (3 patients). No further revisions or complications. Radiographic analyses demonstrated ideal fit of the implant with less than 2 mm subsidence or overhang. KSS pain scores improved from preoperatively 5.7 to 1.7 postoperatively with level walking, and from 7.3 preoperatively to 2.8 postoperatively with climbing stairs or inclines. The WOMAC score improved from preoperatively 43 to 79 postoperatively.

Adipose-derived stromal cells (ASCs) have been investigated as a cell source for tissue regeneration. The purpose of this study was first to confirm if medial meniscectomy induces osteoarthritis (OA) in goats within a relative short period of time, and more importantly, to investigate if systemic treatment with immunosuppressive drugs is necessary in intra-articular ASC xenotransplantation for successful regeneration of articular cartilage and prevention of joint inflammation. Eight Korean native black goats 1–2 years of age underwent medial meniscectomy. To evaluate the gross and histological appearance of articular cartilage, knee joints were re-exposed by a medial parapatellar incision at 8 weeks. After macroscopic scoring of gross appearance, cartilage biopsy specimens 6 mm in diameter were obtained from the femoral condyle in four goats. The goats were injected with single intra-articular dose of 7×106 human ASCs (hASCs) 7 days after the second arthrotomy. Four animals were treated with daily injections of cyclosporin A 10 mg/kg for 7 days, followed by a reduced dose of 5 mg/kg for another 7 days, while other 4 animals did not receive immunosuppressive therapy. All animals were sacrificed for analysis 8 weeks after injection of hASCs. OA was successfully induced 8 weeks after medial meniscectomy. Eight weeks after injection of hASCs, various signs of articular cartilage regeneration were observed. There were no significant macroscopic and histological differences between goats treated with cyclosporine and untreated goats. Interleukin-1ß and tumor necrosis factor-α level from synovial fluid did not differ between cyclosporine-treated and untreated goats. The results indicate that immunosuppressive therapy did not influence the result of ASC xenotransplantation to treat OA.

Background Although the sternoclavicular joint (SCJ) may be involved in ankylosing spondylitis, rheumatic arthritis, and Behçet’s disease and participates in the systemic inflammatory process of arthritis, it is often neglected during routine rheumatologic clinical examinations. To the best of our knowledge, this is the first study to report etanercept treatment in juvenile idiopathic arthritis (JIA) with SCJ involvement. Case presentation In this study, we describe an unusual case of a child with juvenile idiopathic arthritis with an initial presentation of sternoclavicular mass. The patient (age, 14 years 10 months) presented with an insidious onset atraumatic swelling of the left SCJ and complained of right hip and bilateral ankle tenderness without an apparent cause. Initial ultrasonography indicated a heterogeneous mass in the left SCJ, while computed tomography identified mild swelling of the left SCJ with a thickened synovial lining, mild bone erosion, and some turbid fluid. The patient ultimately underwent left SCJ arthrotomy, during which tapping of the SCJ revealed 2 cc of yellowish fluid, inflammation and necrosis of tissues within the SCJ. A clear yellow joint fluid was aspirated, and testing revealed a negative culture result. The patient was diagnosed with JIA. The joint tenderness improved and erythrocyte sedimentation rate decreased after administering anti-tumor necrosis factor etanercept. An additional ultrasonography demonstrated that the initial imaging findings have been resolved. At the end of a 2-year follow-up period, the patient was completely symptom-free. Conclusions JIA with SCJ involvement is an uncommon presentation in adolescents. Etanercept may be a beneficial treatment for SCJ involvement in patients with JIA. The upper limbs showed no signs of limited range of motion during the follow-up period. Further studies are warranted to elucidate the efficacy of etanercept in JIA with sternoclavicular joint involvement.

Background Revision total knee arthroplasty is complex surgery that has to be well planned from its indication to the actual surgical procedure. Objectives To review surgical techniques that allow a secure exposure of the joint in revision total knee arthroplasty. Materials and methods The authors summarize a review of the literature and present their own experience in knee joint exposure aiming to minimize extensor mechanism complications in revision TKA. Results The choice of adequate skin incision, detailed scar removal and a systematic soft tissue release are inevitable prerequisites for an optimal joint exposure and the minimization of extensor mechanism complications. In most patients, a medial parapatellar arthrotomy is sufficient to expose the knee joint and, if necessary, allows a proximal extension using a quadriceps snip or VY-quadricepsplasty, or a distal extension via a tibial tubercle osteotomy. Whether the quick and easy quadriceps snip or a tibial tubercle osteotomy has to be performed depends in each case on the extent of scar formation, the extensor mechanism contracture and the preoperative position of the patella. In general, a parapatellar and lateral release has to be executed; therefore, a partial lateral facetectomy ensures a secure eversion of the patella. Alternative approaches to access the joint do not reveal significant advantages and play a minor role in revision total knee arthroplasty. Conclusion Revision total knee arthroplasty is a challenging surgical procedure. In addition to the regular soft tissue release techniques and joint approaches, the surgeon has to be aware of proximal and distal extension procedures to securely expose the joint and minimize the risk of extensor mechanism complications.

The aim of this study was to compare the efficacy of arthroscopy and arthrotomy in patients with septic monarthritis of the knee. Seventy consecutive patients who underwent surgery because of a bacterial monarthritis were evaluated. Patients were either treated with arthroscopy or with arthrotomy. Our primary outcome was the early recurrence of infection (>3 months after surgery), which made a second surgical procedure necessary. Furthermore, the influence of potential confounders on treatment outcome was analysed. Of the 70 patients, 41 were treated arthroscopically and 29 with arthrotomy. Eight patients (11.4 %) had to undergo a second surgical procedure because of early re-infection. The rate was significantly higher in patients treated with arthrotomy (n = 6; 20.7 %) compared with those treated by arthroscopy (n = 2) (p = 0.041). Range of motion was significantly better in patients who underwent arthroscopy (p

Fungal arthritis is an uncommon yet serious disorder in the newborn. Delay in diagnosis and management can lead to significant morbidity. We report our experience with management of two such cases. Two preterm neonates with multifocal arthritis caused by Candida were studied. Diagnosis was made by clinical examination, laboratory investigations, radiological investigations and culture. Both were treated by aspiration, arthrotomy and antifungal therapy. One patient recovered fully from the infection while the other had growth disturbances resulting in limb length inequality at recent followup. Prompt and expeditious evacuation of pus from joints and antifungal therapy is imperative for treatment. Associated osteomyelitis leads to further difficulty in treatment.

Infrapatellar branch of saphenous nerve (IPBSN) is more prone for injuries during various surgical interventions of the knee. The aim of this study was to know the course and branching pattern of the IPBSN and describe its anatomical variations. To achieve these objectives, we dissected 32 male cadaveric knees. Origin of the nerve was traced in relation with the sartorius muscle; course and terminal branches of the nerve were noted. In majority of the cases (68.7 %), the nerve was found to emerge near the anterior border of sartorius muscle, distance between the medial margin of the patella and the nerve trunk was ranging between 4 and 7 mm. In majority of the cases (65.6 %), division of the nerve trunk was located between the apex of patella and tibial tuberosity. In majority of the cases, single branch was observed (40.6 %). By enriching the knowledge of these variable anatomical position of the IPBSN, surgeon can try to minimize the risk of nerve damage by avoiding the high risk zones while performing medial knee incision, blind puncture or an arthrotomy thus avoiding the unwanted complications.

To report hip synovial fluid cytokine concentrations in hips with and without radiographic arthritis. Patients with no arthritis (Tonnis grade 0) and patients with Tonnis grade 2 or greater hip osteoarthritis (OA) were identified from patients undergoing either hip arthroscopy or arthroplasty. Synovial fluid was collected at the time of portal establishment for those undergoing hip arthroscopy and prior to arthrotomy for the arthroplasty group. Analytes included fibronectin–aggrecan complex (FAC) as well as a standard 12 cytokine array. Variables recorded were Tonnis grade, centre-edge angle of Wiberg, as well as labrum and cartilage pathology for the hip arthroscopy cohort. A priori power analysis was conducted, and a Mann–Whitney U test and regression analyses were used with an alpha value of 0.05 set as significant. Thirty-four patients were included (17 arthroplasty, 17 arthroscopy). FAC was the only analyte to show a significant difference between those with and without OA (p

In monocondylar fractures of the thighbone, the synthesis, with cannulised screws in titanium, under ampliscopic and arthroscopic ray control, allows a good reduction, an early consolidation and rapid functional recovery. The technique gives an early recovery due to the respect of the vascularization and the lack of consequences of the arthrotomy. In this paper the details of the technique used are summarized.

This study investigated the molecular changes of DKK-1, MMP13, Wnt-5a and $$\upbeta $$ -catenin after extracorporeal shockwave therapy (ESWT) in anterior cruciate ligament transected (ACLT) osteoarthritic (OA) knee in rats. 27 male Spraque-Dawley rats were divided into three groups. Group I was the control one and received sham knee arthrotomy but no ACLT or ESWT. Group II underwent ACLT, but no ESWT. Group III underwent ACLT and received ESWT. The animals were killed at 12 weeks, and the harvested knee specimens were subjected to histopathological examination and immunohistochemical analysis. Radiographs of the knees were obtained at 0 and 12 weeks. At 12 weeks, radiographs of group II showed more arthritic changes with formation of osteochondral fragments, whereas very subtle arthritis was noted in groups I and III. In histopathological examination, group II showed a significant increase of Mankin score and a decrease of subchondral bone as compared to groups I and III. Group III showed a significant decrease of Mankin score and an increase of subchondral bone, with the data comparable to group I. In immunohistochemical analysis, group II showed significant increases of DKK-1 and MMP13 and decreases of Wnt-5a and $$\upbeta $$ -catenin in articular cartilage and subchondral bone as compared to groups I and III. Group III showed significant decreases of DKK-1 and MMP13 and increases of Wnt-5a and $$\upbeta $$ -catenin, with the data comparable to group I. In conclusion, the application of ESWT causes molecular changes that are consistent with the improvement in subchondral bone remodeling and chondroprotective effect in ACLT OA knees in rats.

OBJECTIVE Treatment of late and chronic infections, which require the replacement of all the infected implant material. INDICATIONS All infections lasting more than 4 weeks that have been proven to be bacterial and/or obvious signs of infection. CONTRAINDICATIONS Unsuitable for anesthesia, high acute infection with sepsis and risk for bacteremia with danger to life, large soft tissue damage where plastic surgery coverage is not possible. SURGICAL TECHNIQUE Arthrotomy, synovectomy, removal of all foreign bodies including all residue of polymethylmethacrylate (PMMA), jet lavage, spacer, drainage, wound closure or temporary closure using vacuum sealing. POSTOPERATIVE MANAGEMENT Bed rest with a leg brace and drainage until daily drainage volume is

A parapatellar approach disrupts the medial soft tissue stabilizers of the patella. We hypothesized that soft tissue realignment during arthrotomy closure of native cadaveric knees influences patellar kinematics leading to decreased range of motion.Parapatellar arthrotomy was performed in seven native human cadaveric knees that did not contain arthroplasty components. Capsular closure was performed with figure-of-eight sutures in five different positions for each specimen. The capsule was closed anatomically, and then shifted 1.5 or 3 cm distal, or 1.5 or 3 cm proximal relative to surgical markings of the patellar poles. In each closure position, real-time patellar kinematics and range of motion were recorded using a navigation system with patellar tracking function.Maximum knee flexion was significantly reduced with closure shifted 3 cm proximal (133° ± 8.2°, p 0.001) or distal (139° ± 6.4°, p 0.05) compared to anatomical closure (147° ± 4.1°). All closure positions significantly influenced patellar rotation at 45°, 90°, and 120° of flexion (p 0.001). Closure 1.5 or 3 cm distal increased lateral patellar shift relative to the mechanical axis (p 0.01). Patellar tilt was significantly decreased at 90° and 120° by closure 3 cm distal (p 0.01) and at 120° when closed 1.5 cm distal (p 0.05).Imprecise arthrotomy closure significantly impacted patellar kinematics and passive range of motion. Therefore, every effort should be made to provide anatomical closure of the extensor mechanism to preserve native patellar movement kinematics.V.

Sutures are an increasing focus of research in knee arthroplasty (KA). Whether knotless barbed sutures (KBS) are safe and efficient in KA remains controversial. The objective of our study is to compare the clinical outcomes of KA according to wound closure method: KBS versus knotted traditional sutures (KTS). To clarify this, we conducted a systematic review and meta-analysis. Nine articles involving 10 studies were included in this study. The dataset consisted of 1729 patients with 1754 KA. Among these, 814 patients’ wounds were closed with KBS and 915 with KTS. Our analysis indicates that KBS is preferable for KA wound closure given its shorter wound closure time and lower total cost; postoperative Knee Society scores and complication rates were similar to those of surgeries using KTS. The subgroup analysis revealed that closure of arthrotomy with KBS appears to be associated with a lower risk of complications. This meta-analysis indicates that use of KBS in KA reduces operative time and cost. KBS is the preferred option for wound closures, including arthrotomy and reattachment of subcutaneous and subcuticular tissues. Given the possible biases, adequately powered and better-designed studies with longer follow-up are required to reach a firmer conclusion.

We report a case of acute disseminated staphylococcal disease in an 11-year-old boy who had septic arthritis of the left hip, left iliac vein thrombosis and pulmonary embolism. Rapid deterioration was seen in this patient due to the development of disseminated intravascular coagulation. This was further complicated by chicken pox and slipping of the capital femoral epiphysis on the left side following attempted reduction of hip dislocation during follow-up. Closed reduction and percutaneous pinning were performed which failed, resulting in disability. Aggressive management by means of team approach and timely interventions are essential to prevent long-term complications in this life-threatening condition.

Arthrogryposis includes heterogeneous disorders, characterized by congenital contractures of multiple joints. Knee involvement is very common (38-90 % of patients with amyoplasia) ranging from soft-tissue contractures (in flexion or hyperextension) to subluxation and dislocation. Flexion contractures are more common and disabling and show significant resistance to treatment and rate of recurrence. Surgical procedures vary with severity of contracture and patient age and include soft-tissue release, femoral shortening-extension osteotomy, gradual correction with Ilizarov, and femoral anterior epiphysiodesis. The presence of pterygium greatly complicates treatment, given the high rate of complications reported. Hyperextension deformities (recurvatum, anterior subluxation, and dislocation) have better prognosis for walking ability. Surgical options include percutaneous (or mini-open) quadriceps tenotomy, open quadricepsplasty, and femoral shortening osteotomy with limited arthrotomy. Knee dislocations usually require surgery and should be reduced early.

The treatment of large full thickness cartilage defects with matrix guided autologous chondrocyte transplantation shows promising results. However, in many cases an arthrotomy is needed to implant the cell seeded scaffolds. Recently techniques have been developed for arthroscopically guided ACT implantation. Correct defect mapping, to assess size and depth of the chondral lesions, and precise scaffold preparation and fixation are crucial for successful chondrocyte transplantation and remain to be not sufficiently optimized. In the present study, the geometries of two cartilage defects in cadaver knees were three times assessed, measured and transferred to biodegradable scaffolds with a navigation system by three different executors. The scaffolds were arthroscopically implanted into the cartilage defects. The cartilage defect assessment was reproducible between all executors for all defect geometries. The implanted scaffolds showed a correct defect filling. The study showed the feasibility of an arthroscopic implantation of scaffolds for autologous chondrocytes transplantation. Navigation was a useful tool to exactly assess the cartilage defect geometry and allowed a precise transfer of navigated cartilage defect geometries for individualized scaffold preparation. Navigation can help to accomplish and optimize arthroscopically guided chondrocyte transplantations.

Septic arthritis is a serious condition, and, in adults, the knee is the most involved joint. Despite the availability of effective antibiotics, early drainage is essential to minimise the risk of permanent cartilage loss. This study was performed on 42 Holland Dutch rabbits. Two healthy rabbits (group O) were selected to characterise normal histology of the knee joint cartilage and synovium. Forty rabbits were divided randomly into four equal groups after inoculation by 0.5 ml solution of 105 CFU/ml of Staphylococcus aureus in the suprapatellar pouch of the right knee joint. After documentation of septic arthritis, no treatment was prescribed for rabbits in group A (diseased control group). Only antibiotic therapy and splinting were provided for group B. Antibiotic therapy in addition to multiple needle aspirations and splinting for group C and antibiotic therapy plus open arthrotomy drainage and splinting were prescribed for group D. Range of joint motion and pathologic findings of synovium and cartilage for destructive changes were compared in each group. Group D rabbits had less loss of cartilage (p = 0.002) and synovial destruction (p = 0.001) than group C after 3 weeks. Rabbits in group D had minimal loss of joint motion (

Inflammatory or septic arthritis due to Mp is an extremely unusual manifestation in children, and the functional outcome of the joints is difficult to be predicted. Two cases with Mp infection are presented. The first patient had positive PCR for Mp after hip aspiration and arthrotomy with thorough irrigation and debridement. A flattened femoral head was detected during the follow-up, which became quite spherical a year after. An arthrotomy with medial synovectomy of the knee was performed in the second patient. Lack of full knee extension was presented during the first 3 months, which gradually decreased to 7° in the final follow-up. The suspicion of Mp infection with extra-pulmonary involvement in children is mainly based on clinical, epidemiological and radiological data, but laboratory testing is required for confirmation. Rapid diagnosis of probability consists of serum tests, and their results are essential for early therapeutic planning. The direct diagnosis of Mp DNA through polymerase chain reaction (PCR) provides specificity and sensitivity. Very few cases of arthritis associated with Mp infection have been published but not with the severity of our cases. Clinical suspicion of Mp infection is of great importance, and the outcome depends on early diagnosis and specific treatment.

The objectives of the present study were to describe radiographic and magnetic resonance imaging (MRI) findings of early osteoarthritis and their relationships at the same time. A total number of ten rabbits were used and randomly divided into two equal groups. In one group, cranial cruciate ligament (CCL) of the left knee was transected to produce experimental osteoarthritis and in the other group, only the articular capsule was entered as sham operation (arthrotomy group). All of the left knees were examined by MRI and radiography before operation to exclude preexisting abnormalities and serve as control. One month postoperation, two conventional radiographic views and MR imaging were performed under general anesthesia. Statistical analysis of the MRI results revealed that there was a significant difference between the CCL-transected group with arthrotomy and control groups. There was no significant difference in the radiographic findings between the operated, arthrotomy and control groups. It was concluded that osteoarthritic changes of the joints can be detectable 1 month postinjury by MRI. Meniscal degeneration and subchondral bone irregularity are detectable diagnostic signs.

A 9-year-old boy presented with high-grade fever associated with pain and swelling in right hip and left leg of 1-week duration. Pus was found on diagnostic aspiration of the right hip joint. Emergency arthrotomy was performed through anterior approach with drill holes in proximal femur and culture showed MRSA. Intravenous antibiotics were given for 4 weeks. Patient symptomatically improved in immediate postoperative period and in bed hip mobilization was started. On eighth postoperative day, child developed high-grade intermittent fever with chills and rigors and diagnosed as plasmodium falciparum malaria. Fever subsided with antimalarial treatment. On twenty-first day, patient complained pain in right hip and X-ray showed posterior hip dislocation with osteomyelitis of proximal femur. Closed reduction and hip spica application was done under general anesthesia. At follow-up, the clinical result was fair with resolution of infection and stiff hip.

Fibromas that usually occur in the tendon sheaths of the wrist and hand are extremely rare in intra-articular locations. Only five such cases in the knee joint have been reported so far. This is a case report of an intra-articular fibroma of the tendon sheath of the knee joint arising adjacent to posterior cruciate ligament (PCL). Magnetic resonance imaging (MRI) revealed a well-defined intra-articular lesion in the region of the intercondylar notch of the femur behind the PCL. The mass was excised by arthrotomy. Histopathological study confirmed the diagnosis.

Background and aims: An epidemiological analysis of cases of spontaneous community acquired septic arthritis in an elderly population at a university teaching hospital. Methods: Confirmed cases of spontaneous septic arthritis in the over-65 population were studied. Patients with prosthetic joint infections were excluded from the study. Analysed data included initial presenting complaint and clinical examination, hematological and microbiological tests together with ultimate patient outcome. Results: There were 7 confirmed cases of spontaneous septic arthritis in the over 65 population in the past 6 months (2 hips, 5 knees). The mean age was 72.14 (range 65–82) with a mean length of stay of 49 days. Those with septic arthritis of the knee presented with swelling, pain and immobility. Hip cases presented with pain and immobility. All patients were systemically well at the time of presentation, with no other foci of infection detected after septic screening. All patients had confirmed aspirate and arthroscopic/arthrotomy infection. Staphylococcus aureus was isolated from 6 joint aspirations and Pseudomonas Aeruginosa from one patient. Complications of treatment included acute renal failure, cardio/respiratory failure, disseminated infection, and death (1 case). Conclusion: Septic arthritis must be considered as a differential diagnosis in all patients with pint pain, swelling and immobility. This diagnosis is not confined to the pediatric population. A background of degenerative disease and occult presentation in the elderly may delay diagnosis. Sepsis must be considered in the elderly with joint pathology, and treatment must be initiated in a prompt and aggressive manner, to prevent sequelae.

Isolated depression fractures of the femoral condyle are rare, but severe injuries due the destroyed congruency of the articular surface in the weight-bearing region of the joint. In most cases, an arthrotomy with fragment reduction and internal fixation by screws buttress or plates is performed. Disadvantages of this procedure are the approach-related complications. Furthermore, an implant removal is necessary, if a secondary osteoarthrosis develops. We present a female patient with a hyperflexion trauma of her right knee, resulting in an isolated depression fracture of the medial femoral condyle. To avoid arthrotomy-related morbidity, the impressed fragment was retrograde addressed using navigated guidance and reduced indirectly under arthroscopic control. Via the retrograde intraosseous tunnel a biodegradable screw was used as a buttress against the fragment to prevent a re-dislocation. The fracture healed without any complications and the patient re-administered her sports activities at 10 weeks follow-up. This procedure enables an accurate reduction and stable fixation of joint depression fragments via a minimal invasive approach.

The objective of the present study was to determine the magnetic resonance imaging (MRI) and gross pathological findings of articular cartilage in osteoarthritis experimentally induced in rabbit as an animal model. Ten adult Dutch male rabbits were randomly divided into two equal groups. In group one, in the left knee (stifle), the cranial (anterior) cruciate ligament (CCL) was sectioned [transected group (TG)], and in the second group, only arthrotomy was performed through the same approach, but the CCL was left intact [arthrotomy group (AG)]. In both groups, the right knees were considered as controls. Thirty days after operation, MRI was performed under general anesthesia, and then the animals were sacrificed for gross pathological study. MRI was performed by a 1.5-T scanner with a wrist coil to evaluate the coronal and sagittal gradient echo T2-weighted proton density and T1- and T2-weighted sequences. A magnification loupe was used to inspect the menisci, femoral and tibial cartilages, and synovium. The results revealed that the measured mean articular cartilage thickness by MRI was less in TG in comparison to AG and control groups (p < 0.05), whereas the difference between AG and control was not significant. Statistical analysis of the results revealed that the measured mean articular cartilage thickness by MRI was less in TG than those of AG and control groups, whereas the difference between AG and control was not significant. There were no significant differences in meniscal degeneration, joint effusion, and MRI overall grades between AG and the control groups. The difference was significant between TG with AG and the controls in relation to MRI findings. The gross examination revealed that there were no gross abnormalities in AG but there were also significant differences between the TG and AG, and between TG and the controls. Changes were localized primarily to the distal aspect of the medial femoral condylar cartilage. It was concluded that the MRI findings in early osteoarthritis process consisted of articular cartilage loss and meniscal degeneration. The quantitative alterations in articular cartilage thickness measured by MRI can be a noninvasive way to predict osteoarthritis. The MRI findings were also well correlated with the results of pathological study.

Since a dysplastic trochlea has been identified as the main pathomorphology in recurrent patellofemoral instability, trochleoplasty became a surgical solution in some of these cases. However, in comparison to other surgical procedures stabilizing the patellofemoral joint, trochleoplasty is a major operation with an arthrotomy, and associated typical risks of open surgery such as arthrofibrosis. Therefore, we developed a technique to perform an arthroscopic deepening trochleoplasty via suprapatellar portals using shaver burrs. Comparable to the open procedure, a cartilage flake is released and a new bony trochlea is created according to the normal anatomy. Then, the cartilage flake is re-fixated using Vicryl tapes and anchors. This method seems to be an obvious advantage in patellofemoral surgery, since an arthrotomy can be avoided, and postoperative pain as well as soft tissue healing time can be reduced.

Septic arthritis is the most dreaded affection of the joints in children. Early diagnosis, urgent arthrotomy and intravenous antibiotic therapy, however, are essential factors in treatment of septic arthritis to prevent devastating complications. However, the optimal duration of intravenous antibiotic therapy for acute septic arthritis after surgical drainage is not well defined. We performed a prospective study in 93 patients with age less than 5 years who presented with acute septic arthritis and treated with arthrotomy and sequential antibiotic therapy based on determination of serial quantitative CRP levels correlating radiological and clinical outcome. Majority of the subjects (84%) had CRP values more than or equal to 96 mg/dl at the time of presentation. More than half of the subjects had CRP values reverted to normal by the seventh day of treatment. By the 21st day of treatment, all the subjects had CRP values at baseline levels. “The clinical and radiological outcome was excellent in 85% of the cases where the CRP normalized by 7 days compared to 25% where the CRP had not normalized by 21 days.” The difference was found to be statistically significant. We conclude from our study that CRP levels decreases consistently during the antibiotic therapy and patients in whom CRP values return to normal earlier have good clinical and radiological outcomes. We also conclude that intravenous antibiotics should be stopped and switched over to oral therapy once CRP levels return to normal in cases of acute septic arthritis.

Prospective randomised study on the early clinical outcome of anterior midline versus anterolateral incision for total knee arthroplasty (TKA). To assess the early clinical outcome of anterior midline versus anterolateral incision for TKA in terms of wound dehiscence, time for wound healing, lateral flap numbness and knee range of movements. A total of 40 consecutive patients randomly received either anterior midline (midline group; 20 patients, 25 TKAs) or anterolateral skin incision (anterolateral group; 20 patients, 24 TKAs) followed by anteromedial arthrotomy. Postoperatively, the patients were assessed for wound dehiscence, time for wound healing, lateral flap numbness and range of movements. Midline group demonstrated more wound dehiscence, longer healing time and lateral flap numbness compared to anterolateral group. Although the incision was shorter in midline group(P