Development of an intervention to manage knee osteoarthritis risk and symptoms following anterior cruciate ligament injury.

INTRODUCTION: Anterior cruciate ligament (ACL) injury is a risk factor for developing knee osteoarthritis (OA). We developed an intervention to support people manage risk factors for OA. METHODS: We conducted one-on-one interviews with 20 individuals with OA symptoms 6-15 years post ACL injury and used a nominal group process during a workshop with 40 patients and healthcare professionals (HCPs) to elicit information on the intervention content and delivery characteristics (timing, HCPs, and methods). Interview data were analyzed using content analysis. Nominal group ideas with importance ratings ≥5 of 7 met criteria for inclusion. Results were integrated, considering similarities and differences. RESULTS: Eight content categories were identified: 1. understanding knee injury and expectations about recovery; 2. understanding OA risk; 3. understanding OA signs and symptoms; 4. managing OA risk; 5. managing knee OA symptoms; 6. information for influencers; 7. credible sources; and, 8. updates on new evidence and treatments. Delivery timing reflected a lifespan approach from time of injury through symptomatic knee OA management. Although multiple media for delivery were identified, introductory face-to-face discussions and opportunity for re-accessing HCPs were critical. All HCPs who treat people with ACL should be familiar with and able to deliver the intervention. CONCLUSIONS: This co-development approach identified that an intervention to support people with ACL injury to limit and manage knee OA requires content embedded within an easily accessible, multi-media delivery model with capacity for check-back with HCPs that is appealing to different age groups and personal preferences over the lifespan post injury.

Inferior capsular shift operation for multidirectional instability of the shoulder in players of contact sports.

OBJECTIVES: To assess the results of inferior capsular shift for multidirectional instability of the shoulder in athletes. METHODS: Multidirectional instability was surgically corrected in 53 shoulders in 47 athletes who engaged in contact sports. A history of major trauma was found in eight patients, the others having had minor episodes. Before surgery, all patients had complex combinations of instabilities. The surgical approach was selected according to the predominant direction of instability. RESULTS: Anterior inferior capsular shift was carried out in 37 shoulders, and anterior dislocation recurred in three. In one of these, it was anterior alone, one was anterior and inferior, and one was unstable in all three directions. After posterior inferior capsular shift in 16 shoulders, one dislocation occurred anteriorly and one posteriorly. With the anterior approach, four athletes could not return to sport. Two patients treated with the posterior approach could not return to sport. Of these six failures, five patients had had bilateral repairs. Successful repair based on the criteria of the American Shoulder and Elbow Association was achieved in 92% of anterior repairs and 81% of posterior repairs. Successful return to sport was noted in 82% of patients with anterior repairs, 75% with posterior repairs, and 17% with bilateral repairs. Overall, there were five subsequent dislocations, three in the anterior repair group (8%), and two in the posterior repair group (12%). CONCLUSIONS: Inferior capsular shift can successfully correct multidirectional instability in most players of contact sports, but the results in bilateral cases are poor.

Occult osteochondral fractures of the subtalar joint: a review of 10 patients.

Ten patients were treated who had occult osteochondral fractures of the subtalar joint that were not associated with dislocation. Nine osteochondral fractures involved the posterior facet. Seven patients had a stiff and painful subtalar joint, and an arthrodesis was performed. Three patients presented with adequate subtalar joint motion and were treated with physiotherapy. Detection of osteochondral fractures of the subtalar joint is difficult. The "early warning" signs are massive swelling without definitive bone injury on radiographic examination, and a failure to regain subtalar motion after a period of immobilization. Confirmatory evidence is obtained from CT scans or MRI. Initially, aggressive physiotherapy should be considered. Arthrodesis should be used for patients who remain symptomatic.

Anteromedial impingement of the ankle: using MR arthrography to assess the anteromedial recess.

OBJECTIVE: Our objective was to describe the appearance of the anteromedial tibiotalar joint on MR arthrography in patients with clinically and arthroscopically confirmed anteromedial impingement. CONCLUSION: Anteromedial impingement of the ankle is now being recognized in the orthopedic literature as a distinct entity. MR arthrographic findings of anteromedial impingement include capsular and synovial soft-tissue thickening anterior to the tibiotalar ligaments and any associated osseous abnormality. Although anteromedial impingement is uncommon compared with other impingement syndromes of the ankle, the radiologist should be aware of the diagnosis and possible findings on cross-sectional imaging.

Anterolateral ankle impingement: mr arthrographic assessment of the anterolateral recess.

PURPOSE: To determine the accuracy of magnetic resonance (MR) arthrography in assessing the anterolateral recess of the ankle. MATERIALS AND METHODS: Thirty-two patients with chronic ankle pain prospectively underwent gadolinium-enhanced MR arthrography of the tibiotalar joint. All underwent clinical examination and were included if anterolateral impingement (n = 13) or a control condition (n = 19; suspected osteochondral defect, intraarticular bodies, instability, osteoarthritis) was diagnosed. MR imaging included transverse and coronal T1-weighted and sagittal T2-weighted imaging sequences. Images were prospectively analyzed by two readers blinded to the clinical diagnosis. The anterolateral gutter contour was assessed. MR arthrographic findings were correlated with subsequent arthroscopic appearances. RESULTS: MR arthrographic assessment of the anterolateral soft tissues had an accuracy of 97%, sensitivity of 96%, specificity of 100%, negative predictive value of 89%, and positive predictive value of 100%. Accuracy was 100% with clinical anterolateral impingement, with an arthroscopically confirmed abnormality in 12 cases and a normal appearance in one. Anterolateral soft-tissue thickening was identified at MR arthrography in 11 control cases, with arthroscopic confirmation in all. The remaining cases had normal appearances, with an arthroscopic soft-tissue abnormality in one case and a normal appearance in seven. CONCLUSION: MR arthrography of the tibiotalar joint is accurate in assessing the anterolateral recess of the ankle.

Endoscopic bursal resection: the olecranon bursa and prepatellar bursa.

We treated 31 cases of olecranon bursitis and 19 cases of prepatellar bursitis. The average duration of symptoms before surgery was 1.1 years with a range of 3 months to 4 years. All patients had had preoperative aspiration and injection of cortisone. Patients underwent an arthroscopic bursal resection, removing all the bursal sack that could be seen. The results indicated that 86% of patients after olecranon bursectomy had no pain whatsoever. In the patients with prepatellar bursitis, 66% had no pain whatsoever, but we did note some residual tenderness in 24% of the patients, and 10% had pain on kneeling. There were 2 recurrences; 1 patient had rheumatoid arthritis and 1 repetitive daily trauma to the knee. There were no significant complications.

Endoscopic plantar fascia release.

An anatomic exploration showed that reliable landmarks could allow a safe division of the plantar fascia. The reference line was the posterior border of the medial malleolus, 1 cm from the plantar skin. A clinical study on 53 patients (65 feet) showed that, at follow-up of over 2 years, the procedure effectively relieved heel pain in 89% of patients, morning stiffness in 92%, and allowed 71% to return to unrestricted sports activity. There were 2 complications with lateral heel pain. Patients must be properly selected, and must have had the full range of conservative treatment. Symptoms should have been intractable for approximately 1 year. In this group, good results can be expected with minimum short-term morbidity.

Arthroscopic treatment of post-traumatic cysts of the talus.

We report on 9 patients with persistent ankle pain and radiographic evidence of a cystic lesion on the talus. All had a history of an inversion-type of ankle injury. Radiographs were initially negative, but a cyst developed about 6 months after the injury. Arthroscopic debridement revealed extrusion of viscid gelatinous material from the cyst. The cavity was arthroscopically abraded to bleeding base. Follow-up of these patients at an average of 26 months showed statistically significant improvement in terms of pain, swelling, stiffness, limp, and activity level. Bone grafting may not be necessary in the treatment of post-traumatic cysts.

Arthroscopic treatment of osteochondritis dissecans of the talus.

We report on a retrospective study of 33 patients who underwent arthroscopic treatment for osteochondritis dissecans of the talus. Twenty-eight of the patients (85%) had a history of mild to moderate trauma. Arthroscopic treatment consisted of removal of the osteocartilaginous fragments, debridement of disrupted cartilage, and abrasion of the base to bleeding subchondral bone. The average duration of follow-up was 7.4 years with a range of 2 to 18.3 years. Follow-up showed statistically significant improvement in terms of pain, swelling, stiffness, limp, and activity level.

Arthroscopic treatment after previous failed open surgery for osteochondritis dissecans of the talus.

SUMMARY: We report on 8 patients with persistent ankle pain after open surgery for osteochondritis dissecans of the talus. At an average of 35 months after initial surgery, arthroscopic treatment was performed in these patients. The patients had residual loose chondral and osteochondral debris at the site of the original lesion. The remaining loose cartilage was removed and abrasion of the defect to a bleeding base was performed. Follow-up of these patients at an average of 38 months showed statistically significant improvement in terms of pain, swelling stiffness, limp, and activity level.

Chronic pain following ankle sprains in athletes: the role of arthroscopic surgery.

We reviewed 100 patients treated arthroscopically for symptoms of chronic ankle pain associated with sprains of the ankle. All had pain that had failed to respond to conservative treatment for at least 6 months. The pathology in 95 of the 100 ankles studied could be categorized into one of three groups: the instabilities (lateral and syndesmotic), the impingements (anterior and anterolateral), and articular lesions (chondral and osteochondral). Five patients had nonspecific osteoarthritis and/or synovitis on arthroscopy. Patients were followed-up for improvements in six categories: pain, swelling, stiffness, limping, activity, and instability. The primary outcomes of pain and activity were analyzed statistically. Patient satisfaction and return to sports were evaluated. Significant improvements were obtained for patients treated for syndesmotic instability, and anterior and anterolateral impingement. Chondral fractures in the presence of a stable ankle had good results in 75% of cases, compared with those in unstable ankles with only 33% good results. Osteochondritis dissecans was treated successfully by excision of the lesion and abrasion of the base. Patients with chronic lateral instability were treated by open repair, so only the diagnostic arthroscopic findings are reported. We concluded that arthroscopy offered little to the management of lateral instability unless there was considerable doubt regarding the diagnosis. There were minimal improvements for the patients with nonspecific diagnoses such as posttraumatic synovitis. Ankle arthroscopy may be a very useful diagnostic and therapeutic tool in patients who have not responded to conservative therapy.

Pseudoaneurysm as a complication of knee arthroscopy.

This is a report of a pseudoaneurysm of the inferior medial geniculate artery following knee arthroscopy. This case was treated successfully with embolization.

The diabetic frozen shoulder: arthroscopic release.

Seventeen patients who were diabetics developed frozen shoulders which failed to respond to conservative management. They had persistent pain, stiffness, and limited function. An arthroscopic release was performed by progressively releasing the anterior structures from superior to inferior. Starting from the interval area we progressed to the anterior superior glenohumeral ligament, the intra-articular portion of the subscapularis, the anterior capsule, and the inferior capsule. Postoperatively physiotherapy was carried out daily to maintain the range of movement. At a follow up of 1 to 5 years the patients were assessed using the American Shoulder Society scheme. In addition the patients were assessed preoperatively and postoperatively on four criteria; pain, external rotation, abduction, and function. We found that the patients were statistically significantly improved in all four categories. Thirteen of the 17 patients had no pain, full range of motion compared with the opposite side, and full function. There was one poor result with no improvement. The remaining three patients had improved but still had residual abnormalities. We consider arthroscopic release to be an effective treatment for the resistant diabetic frozen shoulder.

Failure of arthroscopic meniscal repair following septic arthritis.

Three cases are described in which failure of arthroscopic meniscal repair performed with an inside-out technique occurred following postoperative septic arthritis. Confirmation of septic arthritis was made by bacterial culture of joint fluid aspirates. The treatment consisted of arthroscopic lavage and intravenous antibiotics. In all cases, diagnostic arthroscopy at the time of lavage showed an intact repair site. However, further follow-up arthroscopy revealed disruption at the repair site with no signs of healing.

Full-thickness rotator cuff tears. A biomechanical comparison of suture versus bone anchor techniques.

We performed a biomechanical comparison of two rotator cuff repair techniques using fresh-frozen human cadavers. Nine pairs of cadaveric shoulders had standardized full-thickness tears made at the supraspinatus tendon insertion. One of each pair of the cadaveric shoulders was repaired by pulling the tendon into a bone trough in the humeral head using standard sutures. The remaining half of the pairs was repaired using anchor sutures. The repairs were tested using a servohydraulically operated material testing system. The anchor suture repair was significantly stronger than the standard suture technique irrespective of bone quality. Failure occurred predominantly through bone in the suture repairs and as a result of suture breakage in the anchor repairs. The anchors should be placed into the edge of the subchondral bone adjacent to the articular surface. The surgeon should direct the anchor so that the direction of the pull is approximately 90 degrees to the anchor, with the humerus at 30 degrees of abduction.

Periarticular heterotopic ossification: a complication of arthroscopic anterior cruciate ligament reconstruction using a two-incision technique.

Extra-articular heterotopic bone formation was recognized as a postoperative complication of arthroscopic anterior cruciate ligament reconstructions in four knees around the femoral drill hole. Although laxity of the reconstructed anterior cruciate ligament was not observed in these patients, local pain, swelling, and deformity at the site of heterotopic ossification required surgical intervention. The ectopic bone can be successfully excised with restoration of function. The incidence rate of this complication is less than 1%.

Fluid pump systems for arthroscopy: a comparison of pressure control versus pressure and flow control.

We set out to compare two pump systems, one in which pressure alone could be controlled and the second in which pressure and flow could be controlled separately. Assessments were carried out by two observers independently. A variety of arthroscopic procedures were studied including arthroscopy of the knee, anterior cruciate ligament reconstruction, arthroscopy and acromioplasty of the shoulder, and arthroscopy of the elbow and ankle. We found that both systems used a similar amount of fluid. However, the operative time was significantly decreased with separate control of pressure and flow. This was related to the fact that there was better visualization and better technical ease with the latter pump. There was significantly less extravasation in the soft tissues. Therefore, based on our assessment, pumps that separately control pressure and flow are significantly better than pumps that control pressure alone. There is distinct advantage in less operative time, greater visualization, technical ease, and less soft tissue extravasation.

The resistant frozen shoulder. Manipulation versus arthroscopic release.

Frozen shoulder is often a self-limited disease, but approximately 10% of patients have long-term problems. Arthroscopy was done in 40 patients with persistent pain, stiffness, and functional loss for at least 1 year without improvement despite conventional treatment. In the first 20 patients, manipulation was done with an arthroscopy before and afterward; in the second 20 patients, the contracted structures were divided through arthroscopy. This was a prospective cohort study; 2 patients were not available for followup. The arthroscopic division procedure was done in 4 sequential steps: (1) resection of the inflammatory synovium in the interval area between the subscapularis and supraspinatus; (2) progressive division of the anterior superior glenohumeral ligament and anterior capsule; (3) division of the subscapularis tendon but not muscle; and (4) division of the inferior capsule. The results were assessed independently on the basis of pain, stiffness, and function. The followup varied from 2 to 5 years after intervention. Patients treated with arthroscopy and manipulation did as well as the patients treated with arthroscopic division for restoration of range of movement. However, the patients in the arthroscopic division group had significantly better pain relief and restoration of function. Fifteen of 20 patients treated with arthroscopic division had an excellent result compared with 7 of 18 patients treated with arthroscopy and manipulation. Patients with diabetes did worse initially, but the outcome was similar to patients without diabetes. Patients with diabetes in particular may benefit from early intervention.

Arthroscopic treatment for posterior impingement in degenerative arthritis of the elbow.

Twenty-one patients underwent arthroscopic treatment for posterior impingement associated with degenerative elbow arthritis. Anterior debridement and removal of loose bodies was performed first. The posterior procedure consisted of three parts: removal of posterior loose bodies, removal of the posterior olecranon osteophyte, and removal of the osteophytes in the olecranon fossa to the point of fenestration. Patients were assessed for pain, strength, motion, stability, and function. They were classified as excellent, good, fair, or poor. Twenty-one of 25 patients were followed an average of 35 months. There was a statistically significant improvement in all criteria. There were 10 good and 11 fair ratings preoperatively; this improved to 14 excellent and 7 good results postoperatively (P = .0001). Arthroscopic treatment for posterior impingement in the degenerative elbow offers substantial improvement with minimal risk, provided proper intraoperative precautions are followed.

Arthroscopic debridement for the osteoarthritic ankle.

We were able to review 27 out of 32 patients who had arthroscopic debridement for osteoarthritis of the ankle. The patients had symptoms for an average of 4 years before the procedure. The average follow up was 45 months. Following arthroscopic debridement, 17 of the 27 patients showed improvement, although only 2 ankles were restored to normal function. There was a statistically significant improvement in pain, swelling, stiffness, limp, and activity level. Changes in the feeling of instability failed to reach significance. Overall, there were 2 complications of numbness related to the anterolateral portal, but these resolved. Arthroscopic debridement of the ankle can offer relief to approximately two thirds of patients, but it is important to stress to patients that the degree of improvement is limited.