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Background: We evaluated the reliability of intraoperative assessment of leukocyte esterase (LE) in synovial fluid samples from patients undergoing reimplantation following implant removal and spacer insertion for periprosthetic joint infection (PJI). Our hypothesis was that a positive intraoperative LE test would be a better predictor of persistent infection than either serum C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) or the combination of serum CRP and ESR. Methods: The records of 76 patients who received a 2-stage exchange for PJI were retrospectively reviewed. Synovial fluid was collected for LE measurement during surgery before arthrotomy in 79 procedures. Receiver operating characteristic curves were generated. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve (AUC) of LE, CRP, ESR, and CRP + ESR were calculated. Results: Sensitivity, specificity, positive predictive value, and negative predictive value of the LE assay were 82%, 99%, 90%, and 97%, respectively. Receiver operating characteristic analysis revealed an LE threshold of 1.5 between the first (negative) and the second (positive) level of the ordinal variable, so that a grade starting from 1+ was accurate for a diagnosis of persistent infection (AUC 0.9044). The best thresholds for the CRP and the ESR assay were 8.25 mg/L (82% sensitivity, 84% specificity, AUC 0.8416) and 45 mm/h (55% sensitivity, 87% specificity, AUC 0.7493), respectively. Conclusion: The LE strip test proved a reliable tool to diagnose persistence of infection and outperformed the serum CRP and ESR assays. The strip test provides a valuable intraoperative diagnostic during second-stage revision for PJI.

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.

Актуальність. Ушкодження ахіллова сухожилля спостерігається в осіб, які ведуть активний спосіб життя або професійно займаються спортом. Хронічне запалення та ушкодження ахіллова сухожилля призводять до стійкої та тривалої втрати працездатності хворого, а також до значних матеріальних затрат на лікування. Мета дослідження: розробити та верифікувати за допомогою магнітно-резонансної томографії експериментальну біологічну модель ушкодження ахіллова сухожилля в лабораторних щурів. Матеріали та методи. Експериментальне моделювання здійснювалося на 10 лабораторних щурах віком до 12 місяців, вагою до 300–350 г. Моделювання травми сухожилля (tendo calvaneus) білих лабораторних щурів виконували хірургічним шляхом за артротомічним типом в асептичних умовах під наркозом. З метою вивчення змін, що відбуваються в ушкодженому сухожиллі, через 7, 14, 21 та 28 діб після хірургічного втручання в щурів проводили магнітно-резонансно-томографічне дослідження ушкодженої зони ахіллова сухожилля. ­Результати. У результаті проведених хірургічних втручань у жодного щура не було виявлено ускладнень як під час хірургічного втручання, так й у післяопераційному періоді. Усі післяопераційні рани зажили первинним натягом. Відповідно до цього всі щури повністю пройшли протокол обстеження. Установлено, що запальний процес в ахілловому сухожиллі продовжується протягом 21 доби після хірургічного втручання, а відновлення дефекту сухожилкової тканини залежить від репаративного потенціалу конкретної особини. Висновки. Розроблено та верифіковано експериментальну біологічну модель тендопатії ахіллова сухожилля, що можна використовувати для досліджень ефективності застосування різних видів лікування.

Background Barbed suture has become popular for closure of the arthrotomy and overlying tissues in total knee arthroplasty. STRATAFIX Symmetric PDS Knotless Tissue Control Device, a unique and novel barbed suture, with barbs formed integral to the suture core provides greater suture strength than the more common cut barbed suture designs. It is the only barbed suture commercially available with an indication in high tension areas, such as fascia. The purpose of this study was to evaluate the use of this novel barbed suture in the formation of a water-tight arthrotomy closure, using a continuous suture pattern, compared to conventional Coated VICRYL (polyglactin 910) Suture, using an interrupted suture pattern, in a cadaveric knee arthrotomy. Methods Twenty fresh-frozen cadaver knees underwent randomization to provide donor-paired matching of the knee arthrotomy closures using barbed suture in a continuous pattern or conventional suture in an interrupted pattern. Each specimen underwent 5 phases of testing that included 1) predynamic static leak testing; 2) dynamic motion leak testing; 3) postdynamic static leak testing; 4) suture release static leak testing; and 5) postsuture release dynamic motion leak testing, to assess the fluid leak rate. Results Under the initial static conditions, watertightness was similar for the 2 types of sutures. However, in all subsequent phases of testing, continuous barbed suture created a better watertight closure than interrupted conventional suture. Conclusions In this study, it was observed that closure of a knee arthrotomy using the novel barbed suture provided improved watertightness compared to conventional interrupted closure under dynamic conditions and suture release.

The administration of lithium chloride (LiCl) for cardiac output (CO) measurement via a peripheral instead of a central vein has been described previously as a valid alternative route in pigs and dogs. The aim of the study was to compare CO measurements after administration of LiCl using two peripheral veins, cephalic or jugular, in goats. Ten adult, female, experimental goats undergoing bilateral stifle arthrotomy were recruited for the study. Paired CO measurements were taken two minutes apart during stable conditions in isoflurane-anaesthetised goats. Forty-two paired CO measurements were taken in total, and the median (range) of paired CO measurement per goat were 4.5 (3–6). The mean (SD) CO using the cephalic and jugular vein for injection of LiCl was 5.28 (1.29) L min−1 and 5.20 (1.24) L min−1 respectively. The Bland-Altman analysis showed an acceptable agreement with a mean bias of 1.33% with limits of agreement (LoA) of −18.43 to 21.09%. The percentage of error was 25%. The four-quadrant plot analysis showed a poor agreement (71%) between the two routes. The polar plot showed a poor trending ability. An 86% inclusion rate (18/21 points) was reached with a ± 35° radial sector size. The findings revealed that the agreement between the two routes is not as precise as the authors expected, however the results are comparable with studies published previously.

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.

Mesenchymal stem cell treatment has become more widely available and has shown promising potential for the repair of knee articular cartilage defects. More recently, open arthrotomy has been performed via a para-patellar incision for cartilage repair using allogenic human umbilical cord blood-derived mesenchymal stem cells (hUCB-MSCs). However, arthroscopy allows better visualization and leads to earlier gain of the range of motion and less scar formation than open arthrotomy, especially in the knee joint. In this study, we present an easy and effective technique for arthroscopic hUCB-MSCs implantation without any special equipment., Technique Video Video 1 This video presents a dry arthroscopy with simple retraction technique for knee joint cartilage repair using allogenic human umbilical cord blood-derived mesenchymal stem cells. It highlights the retraction technique using two spinal needles and suture receiver.

Aims Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. Methods A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml. Results A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin. Conclusion Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702–1708.

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.

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.

PurposeTo assess the feasibility of needle arthroscopy for management of suspected bacterial arthritis in native joints.MethodsDuring a pilot period, patients presenting with symptoms suggestive of native joint bacterial arthritis were eligible for initial management with needle arthroscopy. Procedures were performed in the operating theatre or at the patient bedside in the emergency department or inpatient ward. As our primary outcome measure, it was assessed whether needle arthroscopic lavage resulted in a clear joint. In addition, the need for conversion to standard arthroscopy or arthrotomy, the need for conversion from local to general anaesthesia, complications and the need for additional surgical intervention at follow-up during admission were recorded.ResultsEleven joints in 10 patients (four males, age range 35 – 77) were managed with needle arthroscopy. Needle arthroscopic lavage resulted in a clear joint in all cases. Conversion to standard arthroscopy or arthrotomy was not needed. Seven procedures were performed at the patient bedside using local anaesthesia. These procedures were well tolerated and conversion to general or spinal anaesthesia was not required. There were no procedure complications. One patient received multiple needle arthroscopic lavages. No further surgical interventions beside the initial needle arthroscopic lavage were required for successful management in other cases.ConclusionsNeedle arthroscopy can be a feasible tool in the initial management of complaints suggestive for native joint bacterial arthritis, providing an effective, quick and well-tolerable intervention in the operating theatre or at the patient bedside, with the potential to relief health systems from need for scarce operating theatre time.

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

Purpose To quantitatively compare the articular exposure of the proximal tibia with a lateral parapatellar arthrotomy through a straight midline incision (ML) versus a lateral submeniscal arthrotomy through a curvilinear anterolateral incision (AL). Methods Eight surgical approaches (4 ML and 4 AL) were performed on 4 fresh cadavers. Access to key articular landmarks was assessed, including divisions of the lateral meniscus, lateral tibial spine, and anterior cruciate ligament. The boundary of the exposed articular surface of the tibia was marked, and the proximal tibias were then stripped of soft tissues. A calibrated digital image was taken of each proximal tibia, and exposed articular surface area was calculated with ImageJ software (NIH, Bethesda, MD). Statistical analysis was performed using a two-sample t-test. Results Average articular surface area exposed was 2.2 times greater through the midline approach compared with the anterolateral approach (11.2 vs 5.1 cm2, p = 0.010). All key anatomic landmarks were directly visualized through the midline approach in each specimen. Complete visualization of the lateral meniscus posterior horn, lateral tibial spine, and anterior cruciate ligament was not accomplished through the anterolateral approach in any specimen. Conclusions The midline approach provides more extensive articular exposure of the lateral tibial plateau compared with the anterolateral approach. This improved exposure may offer an advantage when treating fractures not amenable to arthroscopic or minimally invasive techniques. It may be of most use when treating fractures with extension into the posteromedial quadrant of the lateral plateau, fractures with extensive comminution of the lateral plateau, or fractures with complex lateral meniscus tears and fractures with tibial spine involvement.

Purpose To determine the positive predictive values (PPVs) of ICD-9, ICD-10, and Current Procedural Terminology (CPT)-based diagnostic coding algorithms to identify prosthetic joint infection (PJI) following knee arthroplasty (TKA) within the United States Veterans Health Administration. Methods We identified patients with: 1) hospital discharge ICD-9 or ICD-10 diagnosis of PJI, 2) ICD-9, ICD-10, or CPT procedure code for TKA prior to PJI diagnosis, 3) CPT code for knee X-ray within ±90 days of the PJI diagnosis, and 4) at least 1 CPT code for arthrocentesis, arthrotomy, blood culture, or microbiologic procedure within ±90 days of the PJI diagnosis date. Separate samples of patients identified with the ICD-9 and ICD-10-based PJI diagnoses were obtained, stratified by TKA procedure volume at each medical center. Medical records of sampled patients were reviewed by infectious disease clinicians to adjudicate PJI events. The PPV (95% confidence interval [CI]) for the ICD-9 and ICD-10 PJI algorithms were calculated. Results Among a sample of 80 patients meeting the ICD-9 PJI algorithm, 60 (PPV 75.0 %, [CI 64.1-84.0%]) had confirmed PJI. Among 80 patients who met the ICD-10 PJI algorithm, 68 (PPV 85.0%, [CI 75.3-92.0%]) had a confirmed diagnosis. Conclusions An algorithm consisting of an ICD-9 or ICD-10 PJI diagnosis following a TKA code combined with CPT codes for a knee X-ray and either a relevant surgical procedure or microbiologic culture yielded a PPV of 75.0% (ICD-9) and 85.0% (ICD-10), for confirmed PJI events and could be considered for use in future pharmacoepidemiologic studies. This article is protected by copyright. All rights reserved.

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 present initial results of a novel, bi-phasic, porous, biodegrade, and cell-free aragonite-based scaffold for treating complex osteochondral lesions of the talus (OLT). Four subjects (2 males and 2 females; 34-61 years old) were operated on their ankles due to chronic and deep OLT-Hepple grades 4 or 5 (1.8-2.2 cm(2)). Three subjects had OLT on the medial central trochlea, and 1 had a combined medial and lateral lesions. OLT were exposed through medial malleolus osteotomy, with an additional lateral arthrotomy in the combined lesions. Bi-phasic porous osteochondral scaffolds (single implant or 2 implants) were implanted in a press -fit manner using a designated surgical toolset. Treatment outcome was followed clinically (Foot and Ankle Outcome Score, EQ-5D 3L, Tegner activity scale) and by medical imaging (radiographs, magnetic resonance imaging) from 18 to 32 months. All Foot and Ankle Outcome Score values increased from preoperative to final follow-up values (Symptoms 62 to 71, Pain 53 to 84, ADL 60 to 89, Sport 19 to 65, and QoL 18 to 47). EQ-5D 3L increased from 0.59 to 0.76, and Tegner activity values increased from 1.5 to 3. Kellgren-Lawrence ankle radiographic scores remained stable (2 to 2). Postoperative MR evaluation demonstrated cartilage defect fill of 75% to 100% respect to the native cartilage in 3 subjects (4 OLTs), while 1 lesion was filled 25% to 50%. No graft related serious adverse events or graft failures were reported. The use of a bi-phasic osteochondral biodegradable aragonite-based scaffold in the treatment of complex OLT during the reported period presented positive and promising clinical and radiologic outcome, without serious adverse events or graft failures. (C) 2020 by the American College of Foot and Ankle Surgeons.

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.

Background: Internal fixation of an osteochondral lesion of the talus (OLT) can restore the congruency of the talus and maintain the subchondral bone and innate hyaline cartilage. However, OLT that is indicated for fixation is rarely encountered; hence, not many studies report on the results after the procedure. Purpose: To evaluate the clinical and radiological outcomes after internal fixation of chronic OLT involving a large bone fragment of at least 10 mm in diameter and 3 mm in depth on computed tomography (CT). Study Design: Case series; Level of evidence, 4. Methods: We retrospectively reviewed the data of 26 patients with OLT treated with internal fixation between August 2014 and April 2018. Of the patients, 15 were male and 11 were female, with a mean age of 16 years (range, 11-29 years). The primary radiological outcome measurement was bone union assessed on the 6-month postoperative CT scan. Clinical outcomes were assessed at a mean of 27.7 months postoperatively. Results: Twenty patients (77%) achieved bone union on postoperative CT scan. The mean 100-mm visual analog scale (VAS) improved from 30.5 ± 8.5 preoperatively to 13.4 ± 9.7 postoperatively ( P < .001). The mean Foot Function Index (FFI) improved from 30.5 ± 6.7 preoperatively to 13.7 ± 9.8 postoperatively ( P < .001). A malleolar osteotomy was not necessary to approach the lesion in 88% of patients. A bone fragment with an irregular margin and low density on the preoperative CT scan was significantly associated with nonunion (odds ratio: 7.67, 95% confidence interval: 2.67 to 22.02, P = .008). The difference in clinical outcomes between patients with skeletally immature ankles and those with skeletally mature ankles was not statistically significant. Patient age did not correlate with postoperative 100-mm VAS (Pearson correlation coefficient, r = −0.07, P = 0.72) or the postoperative FFI (Pearson correlation coefficient, r = –0.05, P = .80). Conclusion: Internal fixation of an OLT involving a large bone fragment resulted in satisfactory clinical and radiologic outcomes. We found that patients with skeletally immature and mature ankles attained healing at comparable rates after the internal fixation of OLT.

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.

Using an intra-oral scanner for surface and contact evaluation is a novelty in orthopaedics. We introduced this method to compare the congruence between patellar and femoral component surfaces. The compared patellar surfaces were created either with resurfacing, retention of an un-resurfaced patella or patelloplasty, a reshaping method where both facets are resected to match the trochlear surface. In our prospective clinical study, two patients had their patellar surfaces scanned during knee endoprosthesis (Genesis II, Smith & Nephew) implantation, using TRIOS® (3Shape) intraoral laser scanner. Each patient’s patella was scanned three times. First, the original joint surface was scanned after arthrotomy, then scanned again after reshaping the patellar surface and finally scanned after resurfacing with the appropriate standard implant was performed. The acquired surface data were evaluated using CloudCompare software. A mathematical algorithm was used to achieve the best proximity between these surfaces. Distances between the surfaces were measured throughout 0–120° of knee flexion. We defined the measure of proximity as "contact area magnitude". On average, the contact area magnitude was 2.91±0.82 mm using the un-resurfacing method, 3.19±0.95 mm using the resurfaced method and 3.84±0.91 mm using patelloplasty. Leaving the patella un-resurfaced resulted in an improved contact area magnitude. The proximity of the surfaces increased with knee flexion until 75°. With this study, the use of an intra-oral scanner for the surface analysis and intraoperative congruence evaluation was demonstrated. This method could contribute to a better understanding of patellofemoral congruence during total knee arthroplasty.

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..

Introduction: Coccidioidomycosis is a fungal infection endemic to the Southwestern United States, Mexico, and South America. While uncommon, inhalation of spores or direct cutaneous contact can lead to disseminated infection in the immunocompetent, with the involvement of the musculoskeletal and integumentary systems. Case Report: A 49-year-old patient with a history of pulmonary coccidioidomycosis presented with the right knee pain and multiple symptomatic abscesses beneath the suprapatellar and infrapatellar fat pads. Arthrocentesis and culture confirmed the infection, and open synovectomy, arthrotomy, and drainage of the infection were performed without complication. Conclusion: Disseminated coccidioidomycosis is an uncommon fungal infection that may involve joints and become refractory to pharmacotherapy. Management may require surgical intervention, along with infectious disease consultation and close follow-up. Patients from endemic regions should be evaluated with a comprehensive history of this disease. Keywords: Coccidioidomycosis, knee, septic arthritis, arthrotomy, synovectomy, orthopedic surgery, fungal infection.

Resumen: Antecedentes y objetivo: El 40-50% de estas artritis sépticas se producen en la rodilla, y a pesar del rápido tratamiento médico-quirúrgico, del 24 al 50% van a acabar en un pobre resultado clínico. No está claro qué técnica de desbridamiento por artrotomía o por artroscopia es más eficaz para el control de la infección, ni si la artrosis previa empeora o no el resultado. El objetivo de este estudio en artritis séptica de rodilla artrósica es analizar qué técnica de desbridamiento quirúrgico, artroscopia o artrotomía, es más eficaz, cuál es la evolución clínica y radiográfica de los pacientes y cuántos van a necesitar la implantación de una PTR tras la curación de la infección. Material y método: Se realizó un estudio retrospectivo en 27 pacientes con artritis séptica nativa de rodilla. Dieciocho eran hombres y la edad media fue de 64,8 años (30-89 años). Quince pacientes fueron desbridados por artrotomía y 12 por artroscopia. Se analizó la eficacia del desbridamiento para el control de la infección, la progresión radiográfica de la artrosis en la escala de Ahlbäch, la necesidad de protetización posterior y el dolor y el estado funcional mediante la escala EVA y WOMAC a los 52,8 ± 11,2 meses de evolución. Resultados: El 93 y el 92% de los pacientes controlaron la infección, el 13 y el 42% requirieron dos o más cirugías para el control de la infección, y el 18 y el 44,4% mostraron progresión de la artrosis en el grupo artrotomía y artroscopia, respectivamente. Un paciente de cada grupo requirió que se le implantara una prótesis de rodilla. La escala EVA fue superior en el grupo artrotomía y no hubo diferencias en la escala de WOMAC. Conclusión: El desbridamiento por artrotomía en el área de urgencias por cirujanos no subespecializados en rodilla es más eficaz que el artroscópico para controlar la artritis séptica de rodilla. El desbridamiento quirúrgico de las artritis sépticas en rodillas con artrosis previa permite controlar la infección con ausencia de dolor a pesar de la progresión de la artrosis. Abstract: 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. Material and 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 Ahlbäch 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.