Arthroscopy-The Journal of Arthroscopic and Related Surgery最新文献

Hip arthroscopy technique and innovation has revolutionized the surgical approach to femoroacetabular impingement syndrome (FAIS). Arthroscopic labral reconstruction is the gold-standard treatment for irreparable acetabular labral tears in FAIS surgery, and backed by robust long-term clinical data. However, cam-over-resection has become a prevalent complication, often co-occurring with irreparable labral tears in revision FAIS surgery. Revision, circumferential labral reconstruction, is a promising solution, particularly from a biomechanical perspective, in restoring the suction seal. Larger graft width is indicated in these cases.

Effective treatment of scaphoid pseudoarthrosis is critical to reduce the risk of progression to the potentially debilitating scaphoid nonunion advanced collapse including complications of persistent wrist joint instability, degenerative arthritis, decreased range of motion, chronic pain, and functional impairment. Both anatomic and fracture-related pathophysiology predispose patients to scaphoid nonunion, including limited retrograde blood flow, fracture location, and delay of appropriate treatment. Recent studies have demonstrated successful outcomes in treatment of scaphoid nonunions, with non-vascularized bone autograft, commonly from distal radius or iliac crest, as well as pedicled vascularized or free vascularized autograft with union rates varying from 84% to 100%. However, these surgical treatment options require large dissection, prompting a focused interest in minimally invasive arthroscopic options. Theoretically, minimally invasive technique mitigates against devitalizing scaphoid fracture fragments as well as damage to structures such as the joint capsule, ligaments, and already highly tenuous blood supply. Use of olecranon bone graft in combination with a minimally invasive arthroscopic technique and screw fixation is a reasonable option to minimize devitalizing the scaphoid fracture fragments and minimize damage to important soft-tissue structures.

Arthroscopy Techniques is home to technical notes with video on all methods and procedures arthroscopic or related at https://www.arthroscopytechniques.org and https://www.youtube.com/@ArthroscopyTechniques. ATech publications run the gamut from classic to innovative, but where to start if one is a trainee, new in practice, or wishing to expand the breadth of one's practice? To fill this "gap," we introduce the Foundations of Arthroscopy Techniques Collection featuring technical notes with video detailing the essential fundamentals required to perform arthroscopy of the Shoulder, Elbow, Wrist, Hip, Knee, and Foot & Ankle.

Medial opening-wedge high tibia osteotomy (MOWHTO) is a powerful tool in the surgical armamentarium to correct varus malalignment in patients with symptomatic medial compartment disease. This procedure has demonstrated proven results and long-term survivorship. Complications include cortical hinge fracture, symptomatic hardware, infection, delayed or non-union, and nerve injury. Varus recurrence is a known complication following MOWHTO. Risk factors are multifactorial, thought to include degree of alignment correction, extent of meniscus and cartilage pathology, and effectiveness of soft tissue balancing. Medial meniscus extrusion has been implicated in meniscus dysfunction and progression of degenerative joint disease. It is a recognized issue after meniscus preserving and transplant procedures that may have long-term sequela. This loss of hoop stress can lead to increased contact pressure, putting the diseased compartment at further risk. While it is certainly possible that extrusion matters for varus recurrence after MOWHTO, its role must be considered in the context of multiple other confounding factors.

The Latarjet procedure, including coracoid transfer, is indicated for anterior glenohumeral instability and significant bone loss. However, even in experienced hands, the Latarjet procedure is associated with potential complications including neurovascular injury, graft resorption leading to painful or broken hardware and secondary subscapularis damage, prominent hardware, and graft non-union. An adjustable suture button technique may minimize hardware complications, and show low rates of non-union and resorption. (Perhaps, overly rigid fixation of the coracoid using screws contributes to the resorption.) Coracoid transfer may be avoided using various graft sources including iliac crest bone grafting. Despite loss of the "sling effect" provided by coracoid and conjoined tendon transfer, the procedure shows good outcomes with low recurrent instability for indicated patients. While technically complex, bone graft and suspensory fixation may be performed arthroscopically. Time will tell if this technique may supersede the Latarjet.

Adhesions are known to occur following arthroscopic, as well as open surgery of multiple joints, including after hip arthroscopy, resulting in pain, stiffness, and dysfunction. Adhesions of the labrum to the overlying hip capsule can lead to eversion of the labrum, and potentially compromise the suction seal, leading to microinstability and pain. Generally, patient reported outcomes improve after surgical lysis of adhesions, with or without concurrent correction of labral, chondral, or bony pathology. Arthroscopic placement of autograft or allograft spacers may be effective when adhesions between the labrum and capsule prevent an adequate suction seal. Prevention using biologics, such as angiotensin II receptor blockers (e.g., losartan), may inhibit TGF-β1 (transforming growth factor beta 1), which has been associated with fibrogenesis, tissue fibrosis, and scarring. Side effects of losartan are rare but include hypotension, dizziness, angioedema, and acute kidney injury when co-prescribed with NSAIDs, which are often used in heterotopic ossification prophylaxis in hip arthroscopy, and are a significant concern. More data on losartan use is required prior to broader adoption.

Treatment of meniscus injuries have evolved from open to arthroscopic, from total to partial meniscectomy, and towards meniscus preservation. In theory, almost all tear types can be repaired, including root tears, (oblique) radial tears, horizontal cleavage tears, vertical tears, and even complex tears, as a result of improved surgical techniques and tools. Meniscus repair outcomes literature may be confounded by lack of inclusion of control groups, as well as concomitant anterior cruciate ligament injury and reconstruction, augmentation with fibrin clot or platelet-rich plasma or other biologics, suture configuration, and timing of repair. Radial tears represent a most difficult pattern due to limited fixation strength suturing circumferential fibers, and technical challenge. However, successful meniscus repair outcomes can be obtained in this difficult tear pattern. The key to success for any radial repair, regardless of technique, is to create a tensionless repair, and one of the key components is anatomic reduction of the meniscus. Using all inside suture devices to place a traction stitch can assist in reducing the meniscus. Then, AI or IO techniques may be used to repair the meniscus to the capsule in anatomic position (vertical mattress), with rip stop sutures to create horizontal or oblique sutures across the tear. With the meniscus reduced anatomically, mismatch from intra- to extra-capsular distance is prevented.

Medial meniscus extrusion (MME) is classically defined as radial displacement of ≥3 mm outside the tibial border. MME is usually seen in middle age patients and it is strongly associated with medial meniscus root (MMR) pathology and medial femorotibial compartment degenerative change. MMR tears are associated with cartilage defects of the medial femoral condyle (89%) and MME ≥3mm (67%). If MMR tears are associated with MME, high tibial osteotomy (HTO) combined with MMR repair may reduce MME and protect the medial compartment. Recent research shows combined MMR repair and HTO yield improved radiographic and functional outcomes.

Purpose: To evaluate the effectiveness of microfragmented adipose tissue (MFAT) for pain relief and improved joint functionality in knee OA in a randomized, controlled clinical trial with 1-year follow-up.

Methods: Seventy-five patients were stratified by baseline pain level, and randomized to one of three treatment groups: MFAT, corticosteroid (CS), or saline control (C) injection. Patients 18 years of age or older, diagnosed with symptomatic knee osteoarthritis, with radiographic evidence of knee osteoarthritis and a visual analog pain scale (VAS) score of 3/10 or greater were included. Patients were excluded if they had any prior intra-articular knee injection, current knee ligamentous instability or an allergy to lidocaine/corticosteroid. The VAS pain scale, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Knee Injury and Osteoarthritis Outcome score (KOOS) were recorded pre-procedure and at 2 weeks, 6 weeks, 3 and 6 months, and 1 year follow-up.

Results: MFAT demonstrated consistent and statistically significant improvements across all primary outcome measures for joint pain and functionality compared to C. For MFAT, there was a significant improvement over baseline at each follow-up, with median (95% CI) KOOS Pain score changes of 18.1 (11.1, 26.4) at week 2 to 27.8 (19.4, 37.5) at 1 year. For CS, the median KOOS pain score reached a maximum of 22.2 (15.3, 30.6) at week 2, only to level off to 13.9 (-2.8, 29.2), a level not statistically different from baseline, at 1 year. The median changes for C hovered around 6-11 points, with statistically significant improvements over baseline indicating a placebo effect. Similar trends were seen for the WOMAC Pain score and VAS Pain score.

Conclusions: In this study, MFAT demonstrated a clinically significant improvement in primary outcome scores compared with a saline control group, while the corticosteroid group only showed statistically significant improvement compared to the control group at 2 and 6 weeks. This finding indicates that MFAT may be a viable alternative treatment for patients with knee OA that fall into the orthopaedic treatment gap.

Background: The primary purpose was to compare ketorolac to oxycodone-acetaminophen with respect to pain and opioid consumption after arthroscopic meniscus surgery. The secondary purpose was to compare short-term functional outcomes between the two protocols.

Methods: A power analysis demonstrated that 43 patients were required. In this randomized control trial, patients with meniscal pathology undergoing arthroscopic meniscus surgery were included. Group 1 received oxycodone-acetaminophen alone. Group 2 received one dose of intravenous ketorolac intraoperatively, oral ketorolac upon discharge, and "rescue" oxycodone-acetaminophen. Patients recorded the number of opioid tablets consumed and visual analog pain scale (VAS) scores three times per day for five days postoperatively. Opioids were converted to morphine milligram equivalents (MME). VAS, Lysholm Knee Scoring Scale (LKSS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) were obtained.

Results: Forty-eight patients were randomized. There were 25 patients in the control group and 23 patients in the ketorolac group. The mean age was 47.9 (±14.3) years. Fifty-two percent (n=25) of the population were female. Three patients (6.3%) underwent meniscal repair. During the first five days postoperatively, the mean VAS score (β= -13.2, SE=5.97, p=0.029) and the MME consumed were significantly lower (β=-4.7, SE=1.93, p=0.015) per time point in the ketorolac group relative to the control group. The control group had better LKSS (80.6 [SD 18.5] versus 65 [SD 21.5], p=0.016) and KOOS (74.1 [SD 16.7] versus 61.9 [SD 18.6], p=0.029) scores at 6 weeks. There were no significant differences in the rates of side effects.

Conclusions: An opioid-sparing pain protocol of intravenous and oral ketorolac is associated with significant reductions in VAS scores and MME consumption in the first five days after arthroscopic meniscus surgery. There were significant differences in patient-reported outcomes at final follow-up, favoring the control group. There were no significant differences in adverse reactions and side effects.

Level of evidence: Therapeutic Level II, prospective randomized-controlled trial.