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Introduction: The hip is one of the most commonly affected joints in paediatric septic arthritis. Drainage can be performed using arthrocentesis (articular needle aspiration), arthroscopy or arthrotomy. The objective of this systematic review was to identify the most effective drainage technique for septic hip arthritis in the paediatric population. Materials and methods: The electronic MEDLINE, EMBASE and Cochrane databases were systematically searched for original articles that reported outcomes of arthrocentesis, arthroscopy or arthrotomy for septic arthritis of the paediatric hip. Outcome parameters were additional drainage procedures, clinical outcomes and radiological sequelae. The quality of each of the included studies was assessed with the Methodological Index for Non-randomized Studies (MINORS) score. Results: Out of 2428 articles, 19 studies with a total of 406 hip joints were included in the systematic review. Additional arthroscopy or arthrotomy was performed in 15% of the hips treated with arthrocentesis, in 14% after arthroscopy and in 3% after arthrotomy. Inferior clinical outcomes and more radiological sequelae were seen in patients treated with an arthrotomy. A meta-analysis could not be performed due to the diversity and low quality of the studies (MINORS median 4 [range 2–15]). Conclusions: This systematic review gives a comprehensive overview of the available literature on treatment for septic hip arthritis in children. Arthrocentesis and arthroscopic procedures may have a higher risk of additional drainage procedures in comparison with arthrotomy. However, arthrotomy might be associated with inferior outcomes in the longer term. The included studies are diverse and the scientific quality is generally low.

Background Prosthetic joint infection (PJI) of the knee carries significant morbidity, mortality, and economic cost. We hypothesize that obese and poor medical hosts will have a significant and additive increase in failure rate undergoing 2-stage revision total knee arthroplasty for PJI. Methods All 2-stage revision total knee arthroplasty procedures for PJI performed at one institution were identified between 2005 and 2020. In total, 144 patients were included and defined as success or failure based on published criteria regarding infection eradication, further intervention, or mortality. The American Society of Anesthesiologists score and the Charlson Comorbidity Index were utilized to assess host grade. Patient, surgical, and microbiologic variables were investigated with univariable and multivariable analysis to explore association with risk of failure. Results In the cohort, 32.4% of patients failed with mean follow-up of 5.1 years. In multivariable analysis, the number of major operations requiring arthrotomy and implantation of new material between the primary and first stage, host grade, and elevated body mass index were the major contributors to failure. Combining these factors, with body mass index >30 and 2 or more major operations, the failure rate increased to 76.5% and 71.4% respectively for American Society of Anesthesiologists score 3 (P ≤ .001) and Charlson Comorbidity Index ≥2 (P ≤ .001). Conclusion In this cohort, multiple major operations between the primary and first stage, host grade, and obesity were the major contributors to failure. When combining these factors, patients had an additive increase in failure rate. Treatments such as amputation or less invasive options and suppression should be discussed and considered in these patients.

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.

A 7‐year‐old female ostrich (Struthio camelus) presented with lameness, left intertarsal joint swelling and a healing wound on the caudomedial aspect of the joint. Synovial culture revealed Corynebacterium species and radiographs were consistent with progressive septic arthritis. Multiple treatments were attempted including through‐and‐through joint lavage, intra‐articular antibiotics, caudomedial arthrotomy, and regional limb perfusion in conjunction with systemic antibiotics and analgesia. Euthanasia was ultimately performed due to prolonged recumbency and poor prognosis. This report describes novel therapies and a surgical approach utilized for treatment of intertarsal septic arthritis in an ostrich and exemplifies the poor prognosis described in other species presenting with non‐responsive septic arthritis of critical joints., A female ostrich (Struthio camelus) presented with left intertarsal septic arthritis that was culture positive for Corynebacterium. This report describes novel therapies and a surgical approach utilized for attempted treatment of intertarsal septic arthritis in an ostrich and exemplifies the poor prognosis described in other species presenting with non‐responsive septic arthritis of critical joints.

The Latarjet procedure is a method for treating complicated glenohumeral joint dislocation that is often associated with a bone defect in the anterior glenoid. The Latarjet procedure addresses both soft-tissue and bone deficiencies by creating a biceps tendon sling and through bone reconstruction of the anterior glenoid defect. The arthroscopic Latarjet procedure provides good visual control in the structures and eliminates the need for an arthrotomy. We present an arthroscopy-assisted Latarjet technique where the coracoid is temporarily exteriorized to facilitate shaping and preparation for subsequent fixation to the glenoid. Coracoid debridement, anterior glenoid preparation, and the subscapular split are conducted arthroscopically. Cutting the coracoid process is also conducted under arthroscopic control, and the coracoid is exposed through the anteroinferior portal. Once the coracoid is openly shaped and the drill-holes are made, the coracoid is resituated and fixed to the glenoid edge in arthroscopic visual control. The purpose of this technique is to combine favorable elements of the open and arthroscopic procedures. Additionally, the instrumentation is simple, which makes the operation safe and practical to perform., Technique Video Video 1 The patient is placed in the beach chair position. The lateral portal is marked with a needle. The interval is opened exposing the coracoid. The surrounding attachments are removed leaving the conjoined tendon intact. The arthroscope is moved to the lateral portal. All the portals are marked with a needle. It’s very important to get the portals in right places. The antero-inferior portal is opened. The access to the subscapular tendon is made bluntly. The debridement of the coracoid is completed. Especially the coracoid neck area needs to be exposed. The pectoralis minor tendon is released. The conjoined tendon is released from the surroundings. Excessive soft tissue is removed around the subscapular tendon. The anterior glenoid edge is debrided. The glenoid edge is leveled for subsequent coracoid transfer. The subscapular split is conducted viewing through the lateral or anterolateral portal. An internal view of the split. The glenoid edge is now ready for the transfer. A suture-tape is attached to the conjoined tendon. The coracoid is now ready to be cut. At least two centimeters is needed for the coracoid bone graft. The coracoid is cut with an osteotome. The bone-graft is then pulled out through the anteroinferior portal. The bone block is cut to the right size with an oscillating saw. The coracoid is ground flat to match the glenoid edge. Two 4 mm drill holes are made through the bone block with 10 mm offset. The bone block is attached to the Block Passer. The coracoid is secured to the Block Passer with a suture. The coracoid is then transferred back in and through the subscapular opening. The subscapular split may be lifted open with a suture-tape. The block is taken to the glenoid edge. The passer hook gauge helps to orientate the position of the bone block. The block in place the guide pins are drilled through the glenoid bone. The inner sleeve of the block passer is removed. The coracoid bone block is fixed in place with two 4 mm cannulated self-drilling titanium screws. The inferior screw is inserted first and then the superior one. Inserting of the screws can be made in visual control. With the fixation completed the guide wires are removed. The movements of the joint are checked, especially the external rotation.

Upper extremity arthritis in children can be treated with joint aspiration, arthroscopy or arthrotomy, followed by antibiotics. The literature seems inconclusive with respect to the optimal drainage technique. Therefore, the objective of this systematic review was to identify the most effective drainage technique for septic arthritis of the upper extremity in children. Two independent investigators systematically searched the electronic MEDLINE, EMBASE and Cochrane databases for original articles that reported outcomes of aspiration, arthroscopy or arthrotomy for septic arthritis of the paediatric shoulder or elbow. Outcome parameters were clinical improvement, need for repetitive surgery or drainage, and complications. Out of 2428 articles, seven studies with a total of 171 patients treated by aspiration or arthrotomy were included in the systematic review. Five studies reported on shoulder septic arthritis, one study on elbow septic arthritis, and one study on both joints. All studies were retrospective, except for one randomized prospective study. No difference was found between type of treatment and radiological or clinical outcomes. Aspiration of the shoulder or elbow joint required an additional procedure in 44% of patients, while arthrotomy required 12% additional procedures. Conclusion: Both aspiration and arthrotomy can achieve good clinical results in children with septic arthritis of the shoulder or elbow joint. However, the scientific quality of the included studies is low. It seems that the first procedure can be aspiration and washout and start of intravenous antibiotics, knowing that aspiration may have a higher risk of additional drainage procedures. Cite this article: EFORT Open Rev 2021;6:651-657. DOI: 10.1302/2058-5241.6.200122

Controversy still exists regarding how to reduce and fix a displaced tibial avulsion fracture. Open reduction and internal fixation may lead to morbidity due to soft-tissue injury and arthrotomy. As a result, arthroscopic techniques are increasing in popularity. In the literature, sutures, K wires, and screws are suggested to be used as the fixation devices. Screws cannot be used in small or comminuted fractures, whereas K wires and sutures may not provide strong stability. Recently, with the advent of ultrahigh molecular weight polyethylene sutures like FiberWire, it has become possible to use it as the fixation device in even comminuted avulsion fractures with acceptable reduction stability. In this paper, we describe a simple arthroscopic technique using a FiberWire to manage the displaced tibial eminence avulsion fracture., Technique Video Video 1 Our arthroscopic technique for reduction and fixation of ACL avulsion fractures. The patient is in a supine position and his leg is hung from the edge of the table with a leg holder. The visual anterolateral and working anteromedial portal is applied. A cannula is used at the anteromedial portal to facilitate suture passage through the working portal. Two FiberWire sutures are inserted into the joint and tied at each ACL borders (lateral/medial) separately. Two tibial tunnels are drilled from the anteromedial side of the tibia toward the tibial plateau (proximal tunnel endings are set at the medial and lateral sides of the fractured fragment). The endings of the 2 FiberWire sutures are passed through the drilled tunnels and tied on the bone bridge between the 2 tibial tunnels (on a suture disc). (ACL, anterior cruciate ligament.)

Periacetabular osteotomy (PAO) is effective in the management of developmental dysplasia of the hip and femoroacetabular impingement secondary to acetabular retroversion. During anteverting PAO for acetabular retroversion, the need for both labral treatment and femoral head–neck junction osteochondroplasty remains equivocal. Accordingly, this study evaluated patient-reported outcome measures (PROM) and reoperation rates after anteverting PAO with or without intraarticular intervention. Cases of anteverting PAO performed at a single institution between November 2009 and January 2016 were retrospectively reviewed. Patients were divided into three groups: no intervention and intraarticular intervention with arthrotomy or arthroscopy. Subsequently, patients were reclassified by the intraarticular procedure performed at surgery into major (labral repair, femoral head–neck osteochondroplasty) and minor (labral debridement, femoral/acetabular chondroplasty) groups. The cohort was 75% female, median age was 19.5 years and mean body mass index was 25.0 kg/m2. Preoperative to postoperative improvement was compared to minimal clinically important differences (MCID) for eight PROM. Patients receiving major interventions exceeded MCID in a greater proportion of PROM compared to minor and no intervention groups (P

INTRODUCTION Septic arthritis (SA) is a devastating infection with a high rate of sequelae. The aim of this retrospective study was to determine the epidemiology, clinically significant sequelae and risk factors for developing these sequelae in children admitted to our hospital with SA. METHODS Patients with bacteriologically and/or radiologically confirmed SA from January 1999 to December 2014 were identified from discharge and laboratory records. Data was collected through a retrospective review of the case notes. RESULTS A total of 75 patients (62.7% male) met the inclusion criteria. The median age at presentation was six years (range two weeks to 15 years), and six patients were neonates. Microbiologic aetiology was determined in 40 (53.3%) patients, with Staphylococcus aureus being the most common organism. 68.0% of the patients underwent arthrotomy, and the average hospital stay was 15.3 days. Sequelae of SA were observed in nine patients on follow-up. Univariate and multivariate statistical analyses showed that young age, pyogenic bacterial isolation and concomitant osteomyelitis were significant risk factors for developing sequelae. CONCLUSION Our study demonstrated that young age, pyogenic bacterial isolation and concomitant osteomyelitis are associated with a high risk of sequelae. Timely microbiologic diagnosis by novel polymerase chain reaction methods and the use of magnetic resonance imaging in high-risk children to identify adjacent infection could possibly prevent lifelong disabling sequelae in SA.

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.

Purpose: There were 10%–30% of patients with adult-onset septic arthritis (SA) exhibiting sterile synovial fluid (SF), and the uncertainty in the determining diagnosis of these patients posed a challenge in management. The purpose of this study was to investigate the differences between confirmed (Newman A) and suspected (Newman B & C) SA in adults. Methods: This was a descriptive study with a cross-sectional study design conducted at a tertiary referral centre from July 2016 to February 2019. Patients aged over 18 years presented to the emergency department with clinical features suggestive of SA and were scheduled to undergo arthrotomy and joint lavage by the treating surgeon were included in the study. Patients with prosthetic joint infections and open joint injuries were excluded. Patients’ demographic data, clinical features and laboratory parameters were collected. The clinical and laboratory profile (blood and SF) of the adult patients presenting with features suggestive of SA based on Newman criteria was statistically analyzed by SPSS version 20 software and Microsoft Excel. The categorical variables were expressed as proportions while the continuous variables were expressed as mean (SD) or median (IQR) depending upon the normality of distribution. The difference between the two groups for categorical variables was assessed using the Chi-square test and the difference for continuous variables was assessed using the unpaired t-test and the Mann-Whitney test depending upon normality. A p value

Goats or sheep are the preferred animal model for the preclinical evaluation of cartilage repair techniques due to the similarity of the goat stifle joint to the human knee. The medial femoral condyle of the stifle joint is the preferred site for the assessment of articular cartilage repair, as this is the primary location for this type of lesion in the human knee. Proper surgical exposure of the medial femoral condyle is paramount to obtain reproducible results without surgical error. When applying the standard human medial arthrotomy technique on the goat stifle joint, there are some key aspects to consider in order to prevent destabilization of the extensor apparatus and subsequent postoperative patellar dislocations with associated animal discomfort. This paper describes a modified surgical technique to approach the medial femoral condyle of the caprine stifle joint. The modified technique led to satisfactory exposure without postoperative incidence of patellar luxations and no long‐term adverse effects on the joint.

Purpose Synovial neoplasms that affect the small joints, such as the temporomandibular joint (TMJ), are uncommon.1 Of the neoplasms that affect the TMJ, pigmented villonodular synovitis (PVNS), synovial chondromatosis (SC), and juxta-articular myxoma are the most prevalent. To date, there have been only 115 and 360 reported cases of PVNS and SC of the TMJ in the literature, respectively.2 These lesions are locally destructive with the capacity to invade the cranial base and often demonstrate an inconspicuous growth pattern, a high degree of recurrence, and presentation that is confounded with other forms of temporomandibular joint disorder. TMJ arthroscopy has been established as a minimally invasive surgical modality to establish diagnosis and reduce patient morbidity. The purpose of the present study was to evaluate the role and impact of TMJ arthroscopy in the early detection, diagnosis, treatment, and surveillance of PVNS and SC of the TMJ. Patients and methods This is a retrospective case series. Inclusion criteria were patients with synovial neoplasms: specifically, PVNS and SC at Massachusetts General Hospital. Exclusion criteria were patients with malignant tumors involving the TMJ and cranial base and tumors arising from extra-articular, non-synovial origin. Patients were categorized into 2 groups: Group I (who did not undergo early TMJ arthroscopy prior to lesion excision) and Group II (who did undergo early TMJ Level II [multi-port] arthroscopy prior to lesion excision). Pre-operative time to definitive lesion excision surgery, pre-operative biopsy status, extent of surgery (arthroscopic removal vs. open arthrotomy with or without craniotomy), and lesion recurrence were evaluated. Results A total of 6 patients were included in the present study (3 men and 3 women), all unilateral involvement for a total of 6 sides. The mean age was 31 (15-61). Patients were categorized into 2 groups: Group I-3 PVNS patients identified. All patients did not have a pre-operative biopsy prior to lesion excision. Mean pre-operative time duration to definitive lesion removal from initial presentation was 12 months. One isolated open arthrotomy and 2 open arthrotomy with craniotomy were required due to tumor growth and invasion of the middle cranial fossa. Recurrence of the lesion was present in 2 cases requiring repeat excision. Group II consisted of 3 patients: 2 PVNS (Figure 1) and 1 SC (Figure 2). All patients had pre-ablative biopsy diagnosis yielded from arthroscopic synovial biopsy. Mean pre-operative time duration to definitive lesion removal from initial presentation was 7 months. One PVNS case was excised arthroscopically. One isolated open arthrotomy and 1 open arthrotomy with craniotomy were required for definitive lesion excision. No lesion recurrence was noted, with 1 second-look arthroscopy conducted. Conclusion The results from the present study demonstrated that the early TMJ arthroscopy has efficacy in the early detection, diagnosis, and surveillance of synovial neoplasms PVNS and SC. Visualization and synovial biopsy of the lesion provide diagnostic and surgical planning benefit in conjunction with standard pre-operative workup. One lesion was arthroscopically removed. No recurrence has occurred, and TMJ arthroscopy proffers a minimally invasive means for disease surveillance if recurrence is suspected. Larger studies with continued follow-up are needed to further establish the algorithm established by this work to continue to minimize patient morbidity with lesion excision and reduce recurrence rates.

Background: Bicipital tendinitis and/or tendinopathy is a common cause of forelimb lameness in dogs, particularly in larger and more active patients. Although conservative treatment aimed at resolving discomfort and preserving the tendon remains the primary therapeutic goal, in certain cases it is necessary to surgically transect the tendon to eliminate pain and lameness. Transection of the tendon can be performed by open arthrotomy, arthroscopically, or percutaneously using a scalpel blade. This paper examines the utility of a modified percutaneous approach using ahypodermic needle in place of a scalpel blade, under ultrasound-guided assistance.Aim: To develop and describe a surgical technique for performing a percutaneous biceps tenotomy using a hypodermic needle under ultrasound guidance Method: The technique was piloted using the shoulders of 12 cadaver dogs initially and once developed, then applied to another 12 cadavers. The final procedure was performed on a total of 22 shoulders. Assessments were recorded on time to complete the procedure, completeness of bicipital tendon transection, and presence of any iatrogenic damage to associated joint structures. Results: Procedure time averaged fewer than 2 minutes. Complete transection was achieved in 20 out of 22 of the shoulders, with evidence of incomplete transection discernable by ultrasound imaging in the remaining two shoulders. One cadaver shoulder experienced iatrogenic damage secondary to incorrect hypodermic needle angulation. Conclusion: Percutaneous biceps tenotomy using a hypodermic needle is an efficient and straightforward procedure. The lack of a surgical incision makes it the least invasive technique devised so far. Ultrasound imaging allows thepractitioner to assess the completeness of the transection increasing precision.

Introduction: Knee osteoarthritis is a common disabling affection in the elderlies. Rarely the arthritis of knee may be due to ochronotic arthropathy. It is often missed or misdiagnosed as osteoarthritis. An autosomal recessive metabolic disorder characterized by the deficiency of homogentisic acid oxidase enzyme preventing metabolism of homogentisic acid lead to homogentisic aciduria. Alkaptonuria progresses to ochronotic degeneration and arthritis. Early management of ochronotic arthropathy is challenging and is mainly limited to control of symptoms. Advanced cases may necessitate surgery. Case Report: A 65-year-old male presents with persistent progressive pain in both knees, not responding to conservative measures. Patient required simultaneous bilateral cemented total knee arthroplasty for management of arthritic knee pain. Arthrotomy revealed black joints with pigment deposition throughout the articular cartilage and neighboring tissues. Meticulous surgical technique allowed uneventful procedure. Postoperatively patient gained pain-free functional knee movements and was able to ambulate without support within six weeks of arthroplasty. The Knee Society Score improved to 95 bilaterally. At two years, radiologically there was good alignment with no loosening. Discussion: Arthroplasty is an excellent choice for patients with ochronotic arthropathy. However, more information and experience are needed for uniform implant selection and techniques. We report this rare, often missed cause of common knee pain. We review the literature to discuss the specific surgical considerations during knee arthroplasty in such an unusual presentation. Keywords: Alkaptonuria, Ochronosis, Arthropathy, Black joints, Knee arthroplasty..

Background and objective 40%–50% of this septic arthritis occurs in the knee, despite rapid medical surgical treatment, 24%–50% will have a poor clinical outcome. It is not clear which debridement technique, by arthrotomy or arthroscopy, is more effective in controlling infection, or whether or not previous osteoarthritis worsens the outcome. The objective of this study on septic arthritis of the osteoarthritic knee was to analyse which surgical debridement technique, arthroscopy or arthrotomy, is more effective, the clinical and radiographic outcomes of the patients, and how many go on to require a TKR after the infection has healed. Methods A retrospective study was performed in 27 patients with native septic arthritis of the knee. Eighteen were men and the mean age was 64.8 years (30–89 years). Fifteen patients were debrided by arthrotomy and 12 by arthroscopy. The effectiveness of debridement in controlling infection, the radiographic progression of the osteoarthritis on the Ahlbach scale, the need for subsequent replacement, and pain and functional status were analysed using the VAS and WOMAC scales at 52.8 ± 11.2-month follow-up. Results The infection was controlled in 93% and 92% of the patients, 13% and 42% required 2 or more surgeries for infection control, 18% and 44.4% showed progression of arthritis in the arthrotomy and arthroscopy groups, respectively. One patient in each group required a knee replacement. The VAS score was superior in the arthrotomy group and there were no differences in WOMAC score. Conclusion Debridement by arthrotomy in the emergency department by non-sub-specialist knee surgeons is more effective than arthroscopic debridement in controlling septic arthritis of the knee. Surgical debridement of septic arthritis in knees with previous osteoarthritis enabled control of the infection with no pain despite the progression of the osteoarthritis.

Introduction Septic arthritis is a rapid and progressive infection caused by invasion of bacteria into the synovial joint. Disease of the joint causedby Salmonella spp in healthy children is an unusual event, with an estimated incidence of 0.1 to 0.2% of septic arthritis cases among children. The incidence of knee septic arthritis caused by Salmonella typhi with preexisting typhoid fever is very rare. Method We reported a case of 2-years old boy with a history of saddle-type fever 2 weeks prior to right knee pain. Typhoid fever was confirmed by immunoassay test. Knee septic arthritis was established from clinical findings, increased CRP level, ultrasonography, and joint aspiration. Culture of the aspirate subsequently grew Salmonella typhi. This case report had been reported in line with SCARE criteria. Result Arthrotomy and debridement were immediately performed.Intravenous piperacillin tazobactam was given for 6 days and replaced by amoxicillin clavulanic acid after the culture and sensitivity test was available. Patient recovered completely 5 months post surgery and showed excellence result with normal range of knee joint motion. Conclusion This case report suggests that any episode of joint swelling following preexisting typhoid fever should arise the physician’s awareness toward the possibility of septic arthritis and warrant immediate as well as proper management.

Introduction Lacerations and open elbow injuries are common emergency department visits which necessitate an orthopedic surgery evaluation for a traumatic elbow arthrotomy (TEA). A delay in this diagnosis can lead to septic arthritis, requiring more invasive surgical procedures, prolonged antibiotics, and possible long-term sequelae. To date, there is scarce literature on TEA. The purpose of this case report is to better educate the orthopedic community on a reliable method of detection for a TEA, including pediatric patients. Case report Case 1 - Twelve-year-old boy sustained a traumatic dog bite to the right elbow by a large stray dog. Evaluation in the emergency department revealed five 1 centimeter or smaller lacerations over the lateral elbow and another 1 cm laceration to the volar and proximal forearm. A saline load test (SLT) was performed from a posterior approach and was positive after 20cc of normal saline was injected into the joint. An arthroscopic irrigation and debridement were performed as definitive treatment. He was discharged with Augmentin BID for 7 days. Follow-up appointments at 1 and 4 weeks post-operatively revealed no signs of infection.Case 2 - Seven-year-old boy who was in a bicycle accident and sustained a large laceration over the posterior elbow. Evaluation in the emergency department revealed an approximately 15 by 4 cm laceration over the posterior elbow. A SLT was positive after 30cc's was injected from the anterolateral approach. He underwent arthroscopic irrigation and debridement as definitive treatment and was discharged home with Cephalexin BID for 7 days. Follow-up appointments at 1 and 4 weeks post-operatively showed no signs of infection. Conclusion Performing a SLT is a reliable method of detection to evaluate for a TEA. Our case report demonstrated confirmation of TEA in two pediatric patients based on positive SLT. We were able to treat these injuries appropriately with early surgical intervention and prophylactic antibiotics. Our early diagnosis and time-sensitive management prevented septic arthritis based on the patient's short-term follow-up examinations.

Native joint bacterial arthritis is a common infection among adults and children. A solely conservative management, without any articular drainage/lavage, increases the risk of recurrence. In contrast, the type of initial lavage/drainage can be surgical (arthrotomy or arthroscopy) or non-surgical (iterative arthrocenteses). Up to date, no superiority has been shown for any of these approaches in relation to recurrence risk and postinfectious mechanical damage. Furthermore, an initial synovectomy, or the number of iterative drainages does not influence outcome in most cases. Nowadays, an antibiotic regimen of three to four weeks, with early oral therapy, is standard in most settings of the world. In arthritis cases involving the hand and wrist, a shorter systemic antibiotic treatment such as two weeks is sufficient. The outcome of infection is impacted by of mechanical sequelae in up to 40% of cases. These sequels are predominantly joint stiffness and/or osteoarthritis, which are difficult to treat.

Septic arthritis usually represents a direct invasion of joint space by various microorganisms, most commonly caused by bacteria. Most of the time, it is caused by Staphylococci spp. or Streptococci spp. This is a case of a 70-year-old Chinese man with underlying end stage renal failure on regular hemodialysis who presented with recurrent right shoulder pain and swelling. He was diagnosed with right shoulder septic arthritis whereby arthrotomy was performed. Intra-operative tissue specimen from his right shoulder grew Aeromonas hydrophilia which was susceptible to ceftriaxone, cefepime, ciprofloxacin, gentamicin and sulfamethoxazole-trimethoprim. He was given intravenous cefepime for 21 days and discharged after treatment completed. J MEDICINE JUL 2020; 21 (2) : 113-116

Introduction: In 2014 the Consensus Document produced by the Spanish Paediatric Societies (SEIP-SERPE-SEOP) was published to help in the diagnosis and treatment of osteoarticular infections (OAI). In 2015 the RIOPed was considered as a multidisciplinary national network for the investigation into OAI. The aim of this study was to assess the level of adaption to the recommendations established in the Consensus during one year of follow-up. Material and methods: A prospective, national multicentre study was carried out in 37 hospitals between September 2015 and September 2016. The study included patients >16 years-old with a diagnosis of OAI, confirmed by microbiological isolation, or probable: septic arthritis (SA) with >40,000 white cells in synovial fluid, or osteomyelitis (OM)/spondylodiscitis (SD) with a compatible imaging test. The results were compared with those obtained in a retrospective study conducted between 2008 and 2012. Results: A total of 235 cases were included, of which 131 were OM, 79 SA, 30 OA, and 15 SD. As regards the complementary tests that the Consensus considered mandatory to perform, radiography was carried out on 87.8% of the cases, a blood culture on 91.6%, and culture of the synovial fluid in 99% of SA. A magnetic resonance (MR) was performed on 71% of the OM cases. The choice of intravenous empirical antibiotic treatment was adapted to the recommendations in 65.1% of cases, and in 62.3% for the oral treatment. Surgery was performed in 36.8% of SA cases (85.7% arthrotomy), with a significant decrease compared to the retrospective study (P = .014). Only 58.5% of cases followed the recommendations on the duration of the treatment; however, a lower duration of intravenous treatment was observed. Conclusions: In general, the level of adaptation to the recommendations that were set by the Expert Group, is good for the complementary tests, and acceptable as regards the choice of antibiotic treatment, although inadequate in almost 40% of cases. A decrease in hospital stay was achieved. Resumen: Introducción: En 2014 se publicó el Documento de Consenso desarrollado por SEIP-SERPE-SEOP para el diagnóstico y el tratamiento de las infecciones osteoarticulares (IOA). En 2015 se constituyó RIOPed como red nacional multidisciplinar para la investigación en IOA. El objetivo del estudio ha sido valorar el grado de adecuación a las recomendaciones establecidas en el consenso durante un año de seguimiento. Material y métodos: Estudio prospectivo multicéntrico nacional realizado entre septiembre de 2015 y septiembre de 2016 en 37 hospitales con inclusión de pacientes menores de 16 años diagnosticados de IOA, confirmada mediante aislamiento microbiológico, o probable: artritis séptica (AS) con >40.000 leucocitos en líquido sinovial u osteomielitis (OM)/osteoartritis (OA)/espondilodiscitis (ED) con prueba de imagen compatible. Los resultados se compararon con los obtenidos en el estudio retrospectivo realizado entre 2008 y 2012. Resultados: Se incluyeron 255 casos: 131 OM, 79 AS, 30 OA y 15 ED. Respecto a las pruebas complementarias que el consenso consideró de obligada realización, la radiografía se llevó a cabo en el 87,8% de los casos, el hemocultivo en el 91,6% y el cultivo de líquido sinovial en el 99% de AS. Se realizó RM en el 71% de las OM. La elección del tratamiento antibiótico intravenoso empírico se adecuó a las recomendaciones en el 65,1% de los casos, y en el 62,3% para el tratamiento oral. Se llevó a cabo cirugía en el 36,8% de las AS (85,7% artrotomía), con un descenso significativo respecto al estudio retrospectivo (P = ,014). Solo el 58,5% de casos se ajustaron a las recomendaciones de duración del tratamiento; sin embargo, se comprobó una menor duración del tratamiento intravenoso. Conclusiones: En general, el grado de adecuación a las recomendaciones que marcaron el grupo de expertos es bueno para las pruebas complementarias y aceptable respecto a la elección del tratamiento antibiótico, aun detectándose casi un 40% de inadecuación. Se ha conseguido un descenso de la estancia hospitalaria.

ResumoEmbora os tumores lipomatosos sejam comuns, a ocorrência intra-articular é extremamente rara e escassamente descrita na literatura. Em relação a essas entidades raras, a maioria é benigna, tumores de crescimento progressivo e geralmente ocorrem no joelho, mas é crucial distinguir o menos frequente lipoma arborescens (LA) do lipoma sinovial mais raro, pois diferem na apresentação e na patogênese. A ressonância magnética é o exame de escolha na avaliação e no diagnóstico diferencial desses casos, desempenhando um papel central nos dias de hoje.A excisão e sinovectomia, quer artroscópica quer por artrotomia, proporcionam bons resultados com baixas taxas de recorrência. Ao relatar dois casos distintos tratados cirurgicamente de tumores lipomatosos intra-articulares do joelho, os autores pretendem revisar a literatura e discutir sua etiologia, aspectos clínicos e de imagem, bem como a abordagem do tratamento.

Background Patellofemoral arthroplasty (PFA) is an emerging treatment for patients with isolated patellofemoral compartment osteoarthritis. The medial parapatellar approach is the standard arthrotomy but has been shown in total knee arthroplasty to damage the patellar blood supply and increase postoperative patellar instability. The lateral parapatellar approach is an alternative that may reduce the risk of these outcomes. The purpose of this study is to compare the radiographic measures of patellar tracking and patient-reported outcomes of the medial and lateral parapatellar approaches in PFA. Methods Between 2012 and 2019, a retrospective review was performed of 136 knees undergoing PFA at a single institution. Patients were separated by preoperative congruence angle and then surgical approach into 3 cohorts. Preoperative and postoperative patellar tilt and congruence angle were measured. Preoperative and minimum 6-month postoperative patient-reported outcomes scores were collected. Results There were no significant differences in the mean postoperative congruence angle and postoperative patient-reported outcomes among the 3 cohorts. Mean postoperative patellar tilt was normalized only in the abnormal congruence angle/lateral approach group to 2.80° (standard error, 1.85). Conclusion Congruence angle was improved regardless of surgical approach. Patellar tilt was normalized only for the lateral approach in patients with abnormal preoperative congruence angle. There were no significant differences in preoperative and postoperative scores between groups except for preoperative 12-item Short Form Mental Health Survey scores. This study supports that the lateral approach offers improved postoperative patellar tilt compared to a medial approach for PFA while achieving similar patient-reported outcomes.

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.

Introduction: Neonatal septic arthritis has a potential for disastrous sequels with long term disability, especially with joint destruction, instability and growth disturbances. But recent trend shows an increase in fungal septic arthritis. Fungal infections are not readily recognised, do not advertise their presence in a characteristic fashion, and the causative organism is generally not easy to demonstrate in tissue. The purpose of this study was to assess the incidence, identify the risk factors predisposing to fungal infection, its management and outcome. Method: The study was conducted at paediatric hospital in Karnataka. All neonates diagnosed with septic arthritis were included. The neonates were assessed and managed as per our institutional protocol. All cases meeting the criteria underwent arthrocentesis followed by mini-approach arthrotomy of affected joint. The pus was sent for culture and sensitivity, fungal culture and gram staining. Data was collected with regards to organism grown, sensitivity pattern, antenatal, birth history and post-natal period to identify risk factor for infection. Results: 26 of 132 children with septic arthritis had fungal septic arthritis. Candida species was noted to be the most common fungal infection followed by Malassezia furfur. The mean age of patients was 18 days and the mean age of presentation 18 days, 80% of them needed NICU care during first week of life. 65% of them had low birth weight. Hip joint was most commonly affected. 72% had no growth on initial culture and Six had concomitant infection with Klebsiella. 64% had delayed ossification of femur epiphysis and 5 had frank septic sequalae. Conclusion: There is an increasing incidence of fungal septic arthritis and it should be kept in mind while treating a neonatal septic arthritis. Early diagnosis and aggressive line of treatment with a prolonged follow up is needed to reduce the morbidity of the disease.

Background Next-generation sequencing (NGS) offers improved sensitivity compared to culture-based methods for identifying organisms from synovial joints. It remains unclear whether native microorganisms exist in a joint, and positive NGS results may be interpreted as pathologic when in fact they may represent this native microbiome. The purpose of this study was to characterize the native knee microorganism profile in patients undergoing primary total knee arthroplasty (TKA). Methods Forty consecutive patients with osteoarthritis undergoing primary total knee arthroplasty were enrolled prospectively. During TKA surgery but prior to arthrotomy, the native knee was aspirated and the fluid was sent for NGS analysis. Immediately after arthrotomy, four separate tissue samples were also sent for NGS analysis. All microbes identified by NGS were recorded. Results Twelve out of forty patients (30%) had at least one positive organism identified by NGS from their native knee. Of those with positive NGS results, 9/12 (75%) had more than one organism identified (range two to 11). There were no significant differences in demographics, comorbidities, or incidence of prior knee injections between the two groups. There were 48 unique organisms identified from all patients, and the average number of organisms identified by NGS was 4.6 per patient. Four sterile water controls were all negative for organisms. Conclusion A proportion of patients with osteoarthritis undergoing primary total knee arthroplasty have organisms identified in their joint by NGS at the time of surgery. Organisms identified after TKA by NGS when concern for periprosthetic joint infection exists may represent the native microbiome rather than pathogenic microbes.

Hypothesis This study aimed to determine whether there are significant differences in 30-day perioperative complications between arthroscopic and open debridement (irrigation and debridement [I&D]) for septic arthritis (SA) of the shoulder using the American College of Surgeons National Surgical Quality Improvement Program database. Methods Patients undergoing arthroscopic or open I&D of the native shoulder from 2006-2016 were identified in the National Surgical Quality Improvement Program database. Those with a diagnosis of SA were included in the study. Patients with a concurrent diagnosis of osteomyelitis around shoulder (n = 25) or polyarthritis (n = 2) were excluded from the study. Patient demographics, comorbidities, and complications were compared between the groups. Poisson regression, which controlled for age and American Society of Anesthesiologists (ASA) score, was used to calculate the relative risks with 95% confidence intervals for minor adverse events, serious adverse events, total adverse events, and unplanned reoperations between the 2 treatment groups, with significance set at P Results Overall, 147 and 57 patients underwent arthroscopic and open I&D, respectively, for SA of the shoulder. Patients in the open I&D group were more likely to be smokers (P = .0213), whereas patients in the arthroscopy group had higher ASA scores (P = .0008). After controlling for age and ASA score, we found no significant differences in the risk of minor adverse events (P = .0995), serious adverse events (P = .2241), total adverse events (P = .1871), or unplanned reoperations (P = .3855). Conclusion Arthroscopic debridement appears to be a safe alternative to open debridement for SA of the native shoulder. The incidence and risk of 30-day perioperative complications are similar after arthroscopic and open I&D for SA of the shoulder.

Purpose To compare postoperative pain scores and opioid use between patients undergoing a standard arthroscopic anterior cruciate ligament reconstruction (ACLR) using hamstring autograft with those undergoing a suture repair augmented with an extracellular matrix scaffold (bridge-enhanced ACL repair) performed through an arthrotomy and to determine factors predictive of postoperative opioid use and levels of overprescription. Methods A nonrandomized controlled trial was conducted with 20 patients (10 ACLR, 10 bridge-enhanced ACL repair), aged 18 to 35 years. All surgeries were performed by a single surgeon. A pain medication log was provided to patients on discharge. No regional anesthesia was performed. Pain scores via a visual analog pain scale were recorded at each visit. Correlations between preoperative and intraoperative characteristics and postoperative opioid use were determined. Results The total morphine-equivalent dose ranged from 30 to 309 mg (4-42 pills oxycodone) for the ACLR group and 75 to 254 mg (10-34 pills oxycodone) for the bridge-enhanced ACL repair group. The average opioid use per day was 35.8 mg for the patients undergoing bridge-enhanced ACL repair and 44.2 mg for patients undergoing ACLR (P = .29). Pain scores at time points up to 2 years postoperatively were not significantly different between the 2 groups. Across both groups, the average oversupply of oxycodone was 46 pills per patient, a greater than 70% unused opiate rate. Preoperative body mass index and preoperative Knee Injury and Osteoarthritis Outcome Scores pain score were predictive of greater postoperative opioid use per day, whereas age, concurrent meniscal repair, and operative time were not. Conclusions Total overall opiate intake was not different between the patients undergoing bridge-enhanced ACL repair through an arthrotomy and those undergoing arthroscopic ACLR. Both groups had similar pain scores from 2 weeks to 2 years postoperatively. Greater body mass index and greater preoperative pain (lower Knee Injury and Osteoarthritis Outcome Scores pain score) correlated with greater postoperative opioid use per day. There was an overprescription of opioids across all patients. Level of Evidence Level III, case control study (therapeutic).

Septic Arthritis of the wrist is rare in the paediatric population due to its extraarticular metaphysis. We report here a case of wrist septic arthritis in a neonate caused by an uncommon causative organism, Streptococcus cristatus. A 15 days old male child was referred with the complaint of swelling and decreased movement of the left wrist for 5 days. Local examination revealed warm, tender, erythematous and fluctuant swelling over the dorso-ulnar aspect of the left wrist. Ultrasonography of the affected region was suggestive of focal fluid collection in the wrist and periosteal elevation of the distal ulna. Aspiration followed by arthrotomy of the wrist joint was performed and multiple holes were made in the distal ulnar metaphysis using 0.8mm k-wire. The pus culture was positive for Streptococcus cristatus, sensitive to vancomycin, which was given for a total of 4 weeks. At one year follow up the child had a full, painless range of motion with no functional deficit. Final follow up x rays of the left wrist were normal. Streptococcus cristatus strains are described as Gram-positive, catalase-negative cocci, approximately 1 μm in diameter growing in chains and were originally isolated from the human throat and oral cavities. Its association with bone and joint infections has not been described in the literature. To our knowledge, this is the first case of isolated septic arthritis of wrist in a 15 days old child caused by Streptococcus cristatus. To conclude, wrist septic arthritis in a neonate is a rare entity. With the advanced diagnostics, species-level identification of rare organism like Streptococcus cristatus is possible along with antibiotic sensitivity for appropriate therapy. Early surgical decompression and intravenous culture-directed antibiotics are the mainstays of management.

Highlights • Both arthrotomy debridement only or followed by total hip replacement could be an option in treating synovial chondromatosis of the hip. • Both treatment option shows a successful outcome by HHS and LEFS questionnaires without any recurrence marks. • Grade of osteoarthritis and patient age can be a distinguish factor for choosing a treatment option., Introduction Synovial chondromatosis is an unusual nonneoplastic condition of joints. Clinical symptoms usually insidious, and the patient often came in the late stage of the disease. Treatment generally include arthroscopy debridement, open arthrotomy debridement to evacuate loose bodies, or in a very late stage with a collapsing joint, it might need a joint replacement arthroplasty. Methods We report two cases of a 55-year old and a 22-year-old man with synovial chondromatosis of the hip. Both patients came with hip pain, but the former presents at a late stage with osteoarthritis of the hip. The former underwent open arthrotomy debridement to evacuate loose bodies, synovectomy then followed by a total hip replacement. The latter underwent open arthrotomy debridement only to evacuate loose bodies and synovectomy without performing dislocation of the hip. Postoperative outcome was evaluated using plain hip x-ray, pain scale with VAS, and functional score with Harris Hip Score (HHS). Results At 1-year follow up, both subjects demonstrate an improving functional outcome. The former patient had an improved HHS from 39 to 91 while the latter had an improved HHS from 68 to 93. With complete removal of the metaplastic tissue and synovectomy, the recurrence of the chondromatosis is not apparent yet until now. Discussion Arthrotomy debridement only or arthrotomy debridement followed by total hip replacement can be considered as an option in treating synovial chondromatosis of the hip as both show a successful outcome. A selective method of treatment must be considered in our decision making for each individual.

Purpose The purpose of this study was to compare outcomes and reoperation rate between open and arthroscopic treatment of a suspected isolated septic hip in the pediatric population. Methods Retrospective review was performed on two cohorts of pediatric patients who underwent surgical intervention for suspected isolated septic hip arthritis at a single institution. Patients were subdivided into two cohorts based on whether they underwent an open versus arthroscopic approach. Patients were excluded if they received an initial surgery from an outside institution, did not have an acute, active infection at presentation, defined as a hip aspiration leukocyte count

There are several surgical approaches that are currently used to address nondisplaced scaphoid waist fractures, including percutaneous fixation, limited exposure fixation, and traditional open techniques through a volar or dorsal approach. Although percutaneous fixation has some theoretical advantages, it is much more difficult to achieve an accurate starting point for a headless compression screw. The purpose of this paper is to describe a simple, dorsal, mini-open approach to the scaphoid that minimizes incision size, extensor tendon dissection, capsular trauma, and vascular disruption, while still allowing for direct visualization of the proximal pole and optimal exposure for accurate screw placement. As a case report, we retrospectively evaluated 80 consecutive patients with closed scaphoid fractures. There were 2 groups, with 44 patients (age: 24±10 y) receiving a percutaneous dorsal approach and 36 patients (age: 30±16 y) treated with a mini-open approach. All scaphoid fractures were acute or fibrous nonunions (

Bennett lesions, also known as “thrower's exostosis” of the shoulder, involve ossification of the posteroinferior glenoid and are not uncommon in overhead throwing athletes. The literature surrounding the optimal operative management of the symptomatic Bennett lesion is limited. The purpose of this article is to describe the arthroscopic surgical technique for the visualization and excision of the symptomatic extra-articular pathologic ossification involving the posteroinferior glenoid. Because many surgeons may not be familiar with this problem or procedure, we present a straightforward method that allows for identification and excision of the exostosis through an arthroscopic posterior arthrotomy.

Background Although anterior cruciate ligament reconstruction surgery is known to cause joint contracture, the mechanisms of this process are unknown. We aimed to assess the effects of transection of this ligament and each phase of reconstruction surgery on contracture formation. Materials and methods Rats were divided into groups according to treatment received: sham (arthrotomy), ligament transection, ligament transection plus bone drilling, and ligament reconstruction. Surgery was performed on the right knee. Untreated left knees in the sham group were used as controls. Results At 7 and 28 d post-surgery, range of motion before myotomy, mainly representing myogenic contracture, was restricted in the sham and ligament transection groups, and more so in the bone drilling and reconstruction groups. Restricted range of motion after myotomy, representing arthrogenic contracture, was detected at both timepoints in the bone drilling and reconstruction groups, but not in the sham or ligament transection groups. At 3 d post-surgery, although a large blood clot was observed in all three treatment groups, only the bone drilling and reconstruction groups showed significant joint swelling. At 7 d post-surgery, inflammatory-cell infiltration into the joint capsule was most apparent in the bone drilling and reconstruction groups, and joint capsule fibrosis was also most apparent in these groups at 7 and 28 d post-surgery. Conclusions Our results suggest that (1) myogenic contracture after anterior cruciate ligament reconstruction is caused by arthrotomy and aggravated by bone drilling, and (2) arthrogenic contracture is mostly due to bone drilling, which triggers an inflammation-fibrosis cascade.

Objective: Describe patients developing subcutaneous edema after knee arthroscopy. Methods: Personally encountered reported case plus searches using PubMed, Scopus, Web of Science of “subcutaneous edema” and “arthroscopy”. Results: Of 11 cases, 4 could be traced to mishaps during the arthroscopic procedure and two others to non-healing wounds. Edema ranged from chest wall to ankle, and usually appeared several days after arthroscopy. Patients appeared well and did not motivate treatment for gas gangrene, except in one case that underwent fasciotomy and another an arthrotomy. Recovery was complete within 2 days to 3 weeks, with no residual effect on the operated knee. Reported subcutaneous edema follows shoulder arthroscopy more often than knee arthroscopy, and can also complicate arthroscopy of hip and elbow. Conclusion: Subcutaneous edema is a rare dramatic complication of knee arthroscopy with a benign outcome.

We describe a case of septic arthritis caused by Staphylococcus pseudintermedius, a common colonizer of dogs that has emerged as a rare human pathogen. Our patient presented with ankle pain and swelling and was treated adequately with cefazolin/cephalexin and arthrotomy. S. pseudintermedius is often misidentified as other coagulase-positive staphylococcal species and has high rates of methicillin and nonpenicillin antibiotic resistance.

Anterior ankle impingement is a common cause of chronic pain in this site and has synovial chondromatosis, albeit rare, as one of its possible etiologies. Both arthroscopic approach and open arthrotomy are reported as therapeutic option, but the few published data showed that the first is believed to bring more advantages. In a recent study, one of the limitations found by the authors was the rareness of this condition in the ankle, and thus the small number of publications on the topic. We present the rare case of synovial chondromatosis of the ankle in a middle-aged man, which was clinically manifested as anterior impingement syndrome and treated arthroscopically, showing an atypical arboriform vascularization pattern. Level of Evidence V; Diagnostic Studies; Expert Opinion.

Introduction & importance Recurrent chronic synovitis due to foreign body is a rare entity and it may progress into chronic septic arthritis. Chronic recurrent synovitis or septic arthritis may leave permanent damage to the articular cartilage and renders the child with permanent disabilities. Case presentation A 03-year-old girl has been transferred to a tertiary centre with a history of recurrent pain and swelling of the right knee and on and off limping for six weeks duration. These symptoms were preceded by a history of prick injury to the ipsilateral knee. Clinical findings & investigations The knee was warm to the touch, moderately tender and contains effusion. C-Reactive peptide level series were elevated, Erythrocyte sedimentation rate was 83 mm/1 st hour and White cell count was 10,300/mm3. The ultrasonography revealed suprapatellar bursitis, other investigations such as Antinuclear antibody levels, Rheumatoid factor and Bacterial culture of the aspirate were negative. Interventions & outcome Arthrotomy and synovectomy performed. While performing synovectomy, an organic thorn has been retrieved from the Hoffa fat pad. The child was treated with intravenous antibiotics for ten days (Co-amoxiclav) and discharged. Her recovery was uneventful and in six weeks she has shown marked improvement of the knee function. Histological examination revealed non-specific chronic synovitis. Relevance & impact Chronic synovitis due to foreign body mimicking septic arthritis or causing diagnostic difficulty is a rare entity in the paediatric population. Careful clinical evaluation after creating a good rapport with the child is of utmost importance., Highlights • Chronic non-specific synovitis of the knee caused by a septic foreign body causing diagnostic difficulty is a rare entity in clinical practice. • Excluding other conditions causing knee pain and swelling is the first step to diagnosing this entity. • Careful and thorough clinical evaluation after creating a good rapport with the child is of utmost importance to find the initial insult. • The usefulness of Radiographs and Computed tomography are limited in this condition [1]. • Arthroscopic retrieval of foreign body and synovectomy would have reduced the postoperative morbidity.

Case A 45-year-old woman sustained a unique lateral tibia plateau fracture pattern with a vertically rotated fragment composed of an intact articular surface and subchondral bone. During open reduction and internal fixation (ORIF), a full thickness radial tear of the lateral meniscus was found, which was repaired under direct visualization through arthrotomy. At final follow-up, the patient regained pain-free activity with good meniscus healing, as confirmed with a second-look arthroscopic examination. Conclusion This case represents an undescribed fracture pattern that indicates an associated meniscus injury. A thorough evaluation, including Magnetic Resonance Imaging should be considered. One-stage ORIF followed with meniscus repair represents a good treatment option.

Objective To determine clinical profile of osteoarticular tuberculosis (TB) in children. Methods Cross-sectional analysis from 2007 to 2013. All patients diagnosed with bone TB, spinal TB or TB abscesses were included. Results Out of 1318 children with TB, 39 (2.96%) had osteoarticular TB, of which 16 (42%) had osteomyelitis, 8 (20.5%) had spinal involvement, 7 (17.9%) had TB synovitis, 2 (5.1%) had psoas abscess and 6 (15.4%) had abscesses. The mean age of presentation was 7.1 ± 3.5 years (range 2–14 years). Of the 33 cases in which a culture was done, 25 (64%) showed a positive culture. Drug sensitivity tests were done in 21 patients of which 10 (47.6%) tested were drug resistant, of which 4 (36.4%) were multidrug resistant (MDR), 2 (18.2%) were extensively drug resistant (XDR), 3 were pre-XDR (27.3%) and 1 was polyresistant (9.1%). Nine (23.1%) patients had TB in the past with a treatment duration of 8.3 ± 5.3 months. Contact with a TB patient had occurred in 10 (25.6%) cases. Associated pulmonary TB were seen in 6 (15.39%) and TB meningitis were seen in 1 (2.6%) patients. Surgical intervention was needed in 11 (28.2%) patients of which 5 (45.5%) underwent curettage, drainage was done in 1 (9.1%), arthrotomy in 4 (36.4%) and spinal surgery in 1 (9.1%) patient. Conclusion Drug resistant osteoarticular TB is an emerging problem in children.

Background Primary synovial chondromatosis (PSC) is a rare arthropathy of the synovial joints characterized by the formation of cartilaginous nodules, which may detach and become loose bodies within the joint and may undergo secondary proliferation. PSC of the foot and ankle is exceedingly rare, with only a few cases reported in the literature. The diagnosis may be difficult and delayed until operative treatment, when it is confirmed by histological assessment. PSC may degenerate into chondrosarcoma. Operative treatment is the gold standard aiming to minimize pain, improve function, prevent or limit progression of arthritis. Surgical treatment consists in debridement by arthrotomic or arthroscopic management, but there is no consensus in the literature about timing of surgery and surgical technique. Thus, the aim of this study is to report the outcomes of the surgical treatment of two cases, together with a literature review. Case summary We report two cases of patients affected by PSC of the foot in stage III, according to the Milgram classification: the former PSC localized in the ankle that underwent open surgery consisted of loose bodies removal; the latter in the subtalar joint, and the choice of treatment was the arthrotomy and debridement from loose bodies, in addition to the subtalar arthrodesis. Both patients returned to complete daily and working life after surgery. Conclusion Synovial chondromatosis is a rare benign pathology, even rarer in the ankle joint and especially in the foot. Surgery should be minimal in patients with ankle PSC, choosing the correct timing, waiting if possible until stage III. More aggressive and early surgery should be performed in patients with PSC of the foot, particularly the subtalar joint, due to the high risk of arthritic evolution.

Importance Septic arthritis of the native knee joint is the most common bacterial joint infection. The management involves prompt surgical debridement and joint irrigation by arthroscopy or arthrotomy. This is the first systematic review and meta-analysis to compare arthroscopic debridement with arthrotomy for septic arthritis of native knee joint. Objective The purpose of this systematic review and meta-analysis is to compare re-operation rates, length of inpatient hospital stay (LOS) and functional outcome between arthroscopy and arthrotomy in the treatment of acute septic arthritis of the native knee joint. Evidence review This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched from database inception to 31 May 2019. All original studies that compared re-operation rates and LOS between arthroscopy and arthrotomy for septic arthritis of knee were included. The research question and eligibility criteria were established a priori. Pertinent data were extracted and random-effects model was used to pool the data where possible. Findings A total of seven studies with 1089 knees were included, of which 723 underwent arthroscopic surgery and 366 knees underwent arthrotomy. The relative risk of re-operation was significantly lower in the arthroscopy group with a pooled relative risk of 0.69 (95% CI 0.56 to 0.86; p=0.0006). All studies reported shorter LOS and one study reported better functional outcomes in the arthroscopy group as compared with arthrotomy. However, the data could not be quantitatively synthesised due to variation in reporting among the studies included. Conclusions and relevance Based on the available evidence, we conclude that arthroscopy for the treatment of septic arthritis of the knee results in a lower re-operation rate than arthrotomy. It cannot be concluded whether arthroscopic treatment results in shorter LOS or better functional outcome as compared with arthrotomy. Level of evidence IV

Septic arthritis can lead to serious morbidity and mortality. In developing countries most of the cases of septic arthritis presents late, Diagnosis is crucial and often missed. Septic arthritis is already studied, but there is under reporting of neonatal septic arthritis from under developed regions. Aim: To assess the short-term outcome following surgical intervention in patients of neonatal septic arthritis presenting late.Methods: It is a prospective study conducted at tertiary health care center from June 2014 to June 2017. Neonate who presented late (≥ 5 days of symptoms) were included. Total of 110 cases were studied. Diagnosis was made using Modified Kocher’s criteria and USG. Arthrotomy was performed in arthrocentesis positive patients. On follow up Patients were clinically and radiologically reassessed using Bennet Scoring System to check for sequalae. Data was collected and analyzed statistically using SPSS software.Results: Mean total leukocyte count, ESR and CRP were 17,000, 51 and 54 respectively. Excellent results were observed in 10% patients. Good, fair and poor results were obtained in 33.6%, 45.5% and 10.9% patients respectively.Conclusion: Septic arthritis leads to significant morbidity in patients who report late to the specialty even after early surgical intervention. There is a need of awareness programme to educate parents to recognize early features of septic arthritis. The clinicians should pick up and refer the patients as early as possible to the concerned specialty to improve the outcome of neonatal septic arthritic.

INTRODUCTION The clinical, ultrasonographic, radiographic, cytologic and bacteriologic findings, diagnosis and surgical treatment of two heifers with septic metacarpal physitis (type-1 osteomyelitis) and concurrent serofibrinous arthritis of the metacarpophalangeal (MCP) joint are described. Osteomyelitis likely occurred by haematogenous spread following bronchopneumonia in one heifer and developed post-traumatically in the other. In both patients, ultrasonographic examination using the 7.5 MHz linear probe showed moderate effusion of the palmar and dorsal MCP joint pouches and highly irre-gular bone contours with depression and periosteal new bone formation at the metacarpal growth plate. Radiographs showed an extensive radiolucent area with poorly defined margins at the level of the metacarpal growth plate. Surgical treatment was carried out under sedation and regional intravenous anesthesia and involved meticulous debridement of the osteomyelitic lesion of the meta-carpal growth plate combined with arthrotomy of the MCP joint and repeated lavage of the bone cavity and joint. Successful outcomes were achieved by combined use of systemic and locoregional antibiotics, NSAIDs, temporary external coaptation and adequate housing.

Objective: Recent studies indicate that India is an endemic region for Burkholderia pseudomallei infection. We aimed to describe the clinical presentation of B. pseudomallei infection of the musculoskeletal system and summarise the various treatment modalities used in our clinical practice. Subjects and Methods: Patients with confirmed microbiological diagnosis of B. pseudomallei infection involving the musculoskeletal system treated from January 2007 to December 2016 with a minimum follow-up of 1 year were included. A retrospective review of medical records was carried out and patients’ demographic data, co-morbidities, clinical presentation, and details of medical and surgical treatment were documented. Results: Of 342 patients diagnosed with B. pseudomallei infection, 37 (9.2%) had musculoskeletal involvement; 26 patients (23 males) followed up for at least a year were included in the study. Four patients (15%) had multisystem involvement and 10 (37%) had multiple musculoskeletal foci of infection; 15 patients (58%) had osteomyelitis, 10 (38%) had septic arthritis with or without osteomyelitis, and 1 patient (4%) presented with only soft tissue abscess. All patients required surgical intervention in addition to medical management. Surgical treatment varied from soft tissue abscess drainage, arthrotomy for septic arthritis, decompression and curettage for osteomyelitis, and/or use of antibiotic (meropenem or ceftazidime)-loaded polymethylmethacrylate bone cement for local drug delivery. At final follow-up (average: 37 months, range: 12–120), all patients were disease free. Conclusion: We found the rate of musculoskeletal involvement in B. pseudomallei infection to be 9.2%. Appropriate surgical treatment in addition to medical management resulted in resolution of disease in all our patients.

Background Traumatic arthrotomy of the knee (TAK) involves the violation of the knee capsule. TAK differs from simple lacerations because it requires operative management to prevent resultant septic arthritis. The diagnostic test of choice in the emergency department is the saline load test (SLT). SLT sensitivity ranges from 34% to 99%, depending on volume used. Computed tomography (CT) is a possible alternative, using intra-articular air as a diagnostic marker. Ultrasound can identify air in various tissues, given its highly echogenic nature. Objective We sought to determine the sensitivity and specificity of ultrasound for detecting intra-articular air in cadaveric knee joints. Methods Soft embalmed cadavers were utilized. The knees were block randomized to having 1 mL of air injected into the joint or sham skin injection. Two blinded, expert operators scanned the knees with a high-frequency linear transducer. The sensitivity and specificity were calculated. Results Twenty knees were included. Knees that had any prior dissection were excluded from analysis. Ten knees were randomized for air injection. The pooled sensitivity was 0.65 (95% confidence interval [CI] 0.41–0.85) with a specificity of 0.75 (95% CI 0.48–0.93). Mean time taken was 143 s. Conclusions Ultrasound may have utility in evaluation of TAK. There were limitations. Some knees had effusions with echogenic material present, which could have led to false-positive results. It is also unknown how much air is typical of TAK. One milliliter was used based on previous work with CT. The use of ultrasound for diagnosis of TAK warrants further study.

Hodgkin’s lymphoma (HL) is a neoplastic disease of the lymphoid tissue. It is characterised by the presence of B lymphocyte-derived monoclonal Reed-Sternberg and Hodgkin cells, which tend to create a massive inflammation reaction in lymph nodes. Lymphadenopathy is common. The prognosis depends on the clinical stage according to Ann Arbor (Cotswold’s modification) classification and unfavourable prognostic factors. The ABVD chemotherapy regimen is the gold standard of treatment for patients with HL. This case report presents a patient diagnosed and treated for neck presentation of Hodgkin’s lymphoma intricate sepsis and coxarthritis because of Staphylococcus aureus infection. The treatment was arthrotomy. After the patient’s recovery chemotherapy was continued and complete remission was achieved.

Prevotella is a common gram-negative anaerobic rod that is frequently associated with female genitourinary tract infections, pelvic inflammatory disease, aspiration pneumonia, lung abscess and pleural empyema. Osteomyelitis in association with septic arthritis is rare with only a handful of cases reported worldwide. In this case study, we report a patient who presented with a clinical picture of septic arthritis complicated by the presence of a sinus tract at the site of a previous arthroscopic surgery. Initial sinus pus cultures demonstrated Streptococcus agalactiae , which were confirmed with intra-operative joint fluid cultures. After a brief period of clinical improvement following arthrotomy, a sudden clinical deterioration prompted re-cultures demonstrating heavy growth of Provetella bivia . Repeat MRI demonstrated new signs of osseous involvement. The patient was managed with a redo arthrotomy, extensive debridement of osteomyelitic tissue, washout and an extended antibiotic therapy regimen. This association is first of its kind in Saudi Arabia. J Microbiol Infect Dis 2019; 9(2):100-103.

Objective To determine whether there are differences in the outcomes of native joint septic arthritis (SA) in adults, based on medical versus surgical management. Methods A 10-year retrospective single-center study was conducted of patients admitted to a tertiary care hospital between January 1, 2006 and December 31, 2015 with a diagnosis of SA to compare outcomes based on the management approach taken: medical (bedside closed-needle joint aspiration) versus surgical (arthrotomy/arthroscopy). Evaluated outcomes included joint recovery, time to recovery, length of stay, disposition to home versus rehabilitation unit, recurrence of SA in the same joint, and mortality. Results Of 118 confirmed cases of SA, 48 were in prosthetic joints and 70 were in native joints, and 61 met our inclusion criteria. Forty-one (67%) patients received surgery, and 20 (33%) received closed-needle aspiration. There was no statistically significant difference in long-term outcomes between the two groups at 12 months. Patients managed medically were more likely to experience full recovery at 3 months and were less likely to need short-term rehabilitation. Conclusions Medical management with closed-needle aspiration may be an adequate approach to the treatment of native joint infections.

Early joint decompression associated to antibiotic therapy is the most important procedure to reduce joint damage in septic knee arthritis in children. Several joint decompression methods have been described such as arthrotomy with open debriding, arthroscopic drainage or needle joint aspiration. The aim of the present study was to determinate which patients with acute septic knee arthritis could be safely treated with needle joint aspiration.Patients with an acute knee arthritis diagnosed between September 2003 and December 2013 in our children's tertiary hospital were retrospective review. All cases were initially treated with needle joint aspiration. Primary end-point was failure of joint aspiration.A total of 74 patients were included in the study. Forty-two (56.8%) were male and median age was 1.49 years. Mean delay between onset of symptoms and diagnosis was 3.6 days and in 25 (33.8%) cases patients needed more than 1 visit to the emergency room. Median C-reactive protein (CRP) value was 36.3 mg/L and was20 mg/L in 59 (79.7%) cases. A total of 11 (14.9%) patients showed failure of the joint aspiration treatment between 3 and 21 days after initial joint aspiration. The stepwise forward logistic regression model only identified as independent predictor of joint aspiration failure an age older than 3 years old (odds ratio, 5.64; 95% confidence interval, 1.38-29.61; P=0.018). Joint aspiration did not fail in any patient younger than 12 months and neither in any patient younger than 3 years old with CRP value20 mg/L. Otherwise, treatment failed in 38% of patients older than 3 years and in 16% of patients between 1 and 3 years with a CRP20 mg/L.Septic knee arthritis treated with needle joint aspiration succeed in all patients younger than 1 year and in all patients between 1 and 3 years with a CRP20 mg/L. Alternative treatment such as arthroscopy debridement should be early considered in patients older than 3 years and patients between 1 and 3 years with CRP20 mg/L.Level III.