Will rheumatologists ever pick up the arthroscope again?

Conditions prompting physicians and surgeons first adapting endoscopes to peer into joints were mainly the sort of synovial conditions that would concern today's rheumatologists. Rheumatologists were among the pre-World War II pioneers developing and documenting arthroscopy. The post-War father of modern arthroscopy, Watanabe, found rheumatologists among his early students, who took back the technique to their home countries, teaching orthopedists and rheumatologists alike. Rheumatologists described and analyzed the intra-articular features of their common diseases in the '60s and '70s. A groundswell of interest from academic rheumatologists in adapting arthroscopy grew considerably in the '90s with development of "needle scopes" that could be used in an office setting. Rheumatologists helped conduct the very trials the findings of which reduced demand for their arthroscopic services by questioning the efficacy of arthroscopic debridement in osteoarthritis (OA) and also developing biological compounds that greatly reduced the call for any resective intervention in inflammatory arthropathies. The arthroscope has proven an excellent tool for viewing and sampling synovium and continues to serve this purpose at several international research centers. While cartilage is now imaged mainly by magnetic resonance imaging, some OA features - such as a high prevalence of visible calcinosis - beg further arthroscopy-directed investigation. A new generation of "needle scopes" with far superior optics awaits future investigators, should they develop interest.

Oxycodone-paracetamol tablet exhibits increased analgesic efficacy for acute postoperative pain, higher satisfaction and comparable safety profiles compared with celecoxib in patients underwent arthroscopic knee surgery.

This randomized, controlled study compared the efficacy and safety between oxycodone-paracetamol tablet and celecoxib for postoperative analgesia in patients who underwent arthroscopic knee surgery (AKS). Totally, 232 patients scheduled to undergo AKS were enrolled and were randomly assigned to either the oxycodone-paracetamol (OPT group) or the celecoxib group (CEL group). Pain at rest/motion (based on pain visual analog scale (VAS) score), rescue analgesia consumption, satisfaction level and adverse events were assessed after AKS. Pain VAS score at rest was decreased at 6 h, 12 h post-AKS in the OPT group compared with the CEL group. Similarly, pain VAS score at motion was reduced at 6 h, 12 h, 24 h post-AKS in the OPT group compared to the CEL group. Furthermore, both rescue analgesia rate (14.7% vs. 33.6%) and accumulated pethidine consumption (3.7 ± 8.9 mg vs. 14.0 ± 21.2 mg) were lower in OPT group compared with the CEL group. Patients satisfaction score was either at 24 h, 48 h in OPT group compared with the CEL group. Further subgroup analyses indicated that the effect of oxycodone-paracetamol versus (vs. celecoxib) on post-AKS management was more apparent in the elderly patients and male patients. In addition, the adverse events were well tolerable (including nausea, constipation, vomiting, drowsiness and dizziness) and were of no different between the two groups. In conclusion, oxycodone-paracetamol tablet presents increased analgesic efficacy for acute postoperative pain, with higher patient satisfaction and comparable safety profiles compared with celecoxib in patients underwent AKS.

Arthroscopy Annual Awards: The "Old Normal".

With sincere thanks to the Arthroscopy Association of North America Education Foundation for their support, we are pleased to announce the Annual Awards for our best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2020, as well as the Most Downloaded and Most Cited papers published 5 years ago. We proudly introduce new members of our editorial team, and your editors update their disclosures of potential conflicts of interest.

Lower nationwide rates of arthroscopic procedures in 2016 compared with 1997 (634925 total arthroscopic procedures): has the tide turned?

OBJECTIVES: To assess the rates and secular trends of different joint arthroscopies-shoulder, elbow, wrist, hip, knee and ankle-in Finland between 1997 and 2016. DESIGN: Retrospective nationwide registry study. PARTICIPANTS: All adults in Finland with any arthroscopic intervention procedure code for knee, shoulder, ankle, wrist, elbow or hip arthroscopy between 1 January 1997 and 31 December 2016 were included. MAIN OUTCOME MEASURES: Incidence rate of arthroscopic surgery per 100 000 person-years. RESULTS: The rate of knee and shoulder arthroscopies declined after reaching a peak in 2006 and 2007, respectively. The rates of wrist, elbow and hip joint arthroscopies declined after their 2014 peak. At the same time, the median age of patients who had knee, ankle and hip arthroscopy decreased, whereas the age of patients who had shoulder arthroscopy increased. CONCLUSIONS: Numerous randomised controlled trials point to lack of efficacy of the most common knee and shoulder arthroscopic procedures. It should not be assumed that this has contributed to decreased rates of arthroscopic surgery. The concurrent decrease in most of the other joint arthroscopic procedures was unexpected.

Trends in Adolescent Hip Arthroscopy From the PHIS Database 2008-2018.

BACKGROUND: Previous studies have suggested that hip arthroscopy has been performed with increasing frequency. Few studies have examined this trend in the adolescent population. The purpose of this study was to evaluate the trend in the frequency of hip arthroscopy in adolescents standardized by total orthopaedic surgeries in adolescents at pediatric hospitals in the United States. METHODS: The Pediatric Health Information System (PHIS) database was queried for patients aged 10 to 19 years who underwent orthopaedic surgery at any of the PHIS-participating hospitals from 2008 to 2018. The subgroup of patients in this age cohort who underwent hip arthroscopy was identified using Current Procedural Terminology procedure codes. The yearly rate was expressed as the number of hip arthroscopies per 1000 orthopaedic surgeries. A linear model was used to fit the data and illustrate the relative trend. RESULTS: A total of 432,309 orthopaedic surgeries including 9491 hip arthroscopies were performed for patients 10 to 19 years of age. Hip arthroscopies were performed at a yearly rate of 22 per 1000 orthopaedic surgeries. Over the 10-year period, the number of hip arthroscopies increased 6.2-fold, whereas the number of orthopaedic procedures increased 1.6-fold. There was a 3.9-fold increase in hip arthroscopies relative to total orthopaedic surgeries. CONCLUSIONS: The number of hip arthroscopic procedures in adolescent patients has increased by 3.9-fold times relative to total orthopaedic surgeries in adolescents over a 10-year span, on the basis of data from PHIS-participating institutions. This finding mirrors the trends in the adult population over similar time periods. This may be because of increasing participation in sports in the adolescent population, and a better understanding of the diagnosis and treatment of femoroacetabular impingement and other sports-related hip pathologies. LEVEL OF EVIDENCE: Level IV.

Management of Achilles and patellar tendinopathy: what we know, what we can do.

Tendinopathies are challenging conditions frequent in athletes and in middle-aged overweight patients with no history of increased physical activity. The term "tendinopathy" refers to a clinical condition characterised by pain, swelling, and functional limitations of tendons and nearby structures, the effect of chronic failure of healing response. Tendinopathies give rise to significant morbidity, and, at present, only limited scientifically proven management modalities exist. Achilles and patellar tendons are among the most vulnerable tendons, and among the most frequent lower extremity overuse injuries. Achilles and patellar tendinopathies can be managed primarily conservatively, obtaining good results and clinical outcomes, but, when this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions, and, if performed well, they lead to a relatively high rate of success with few complications. The purpose of this narrative review is to critically examine the recent available scientific literature to provide evidence-based opinions on these two common and troublesome conditions.

The role of regional analgesia in personalized postoperative pain management.

Pain management plays a fundamental role in enhanced recovery after surgery pathways. The concept of multimodal analgesia in providing a balanced and effective approach to perioperative pain management is widely accepted and practiced, with regional anesthesia playing a pivotal role. Nerve block techniques can be utilized to achieve the goals of enhanced recovery, whether it be the resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can be daunting for general anesthesiologists. Which is the most appropriate regional technique to choose, and what skills and infrastructure are required for its implementation? A multidisciplinary team-based approach for defining the goals is essential, based on each patient's needs, and incorporating patient, surgical, and social factors. This review provides a framework for a personalized approach to postoperative pain management with an emphasis on regional anesthesia techniques.

Open versus arthroscopic ankle arthrodesis: a systematic review and meta-analysis.

BACKGROUND: Osteoarthritis (OA) is a growing health concern that affects approximately 27 million people in the USA and is associated with a $185 billion annual cost burden. Choosing between open surgery and arthroscopic arthrodesis for ankle arthritis is still controversial. This study compared arthroscopic arthrodesis and open surgery by performing a systematic review and meta-analysis. METHODS: For the systematic review, a literature search was conducted in 4 English databases (PubMed, Embase, Medline and the Cochrane Library) from inception to February 2020. Three prospective cohort studies and 7 retrospective cohort studies, enrolling a total of 507 patients with ankle arthritis, were included. RESULTS: For fusion rate, the pooled data showed a significantly higher rate of fusion during arthroscopic arthrodesis compared with open surgery (odds ratio 0.25, 95% CI 0.11 to 0.57, p = 0.0010). Regarding estimated blood loss, the pooled data showed significantly less blood loss during arthroscopic arthrodesis compared with open surgery (WMD 52.04, 95% CI 14.14 to 89.94, p = 0.007). For tourniquet time, the pooled data showed a shorter tourniquet time during arthroscopic arthrodesis compared with open surgery (WMD 22.68, 95% CI 1.92 to 43.43, p = 0.03). For length of hospital stay, the pooled data showed less hospitalisation time for patients undergoing arthroscopic arthrodesis compared with open surgery (WMD 1.62, 95% CI 0.97 to 2.26, p < 0.00001). The pooled data showed better recovery for the patients who underwent arthroscopic arthrodesis compared with open surgery at 1 year (WMD 14.73, 95% CI 6.66 to 22.80, p = 0.0003). CONCLUSION: In conclusion, arthroscopic arthrodesis was associated with a higher fusion rate, smaller estimated blood loss, shorter tourniquet time, and shorter length of hospitalisation than open surgery.

Implementation of the Obturator Nerve Block into a Supra-Inguinal Fascia Iliaca Compartment Block Based Analgesia Protocol for Hip Arthroscopy: Retrospective Pre-Post Study.

Background and Objectives: The effect of supra-inguinal fascia iliaca compartment block (SI-FICB) in hip arthroscopy is not apparent. It is also controversial whether SI-FICB can block the obturator nerve, which may affect postoperative analgesia after hip arthroscopy. We compared analgesic effects before and after the implementation of obturator nerve block into SI-FICB for hip arthroscopy. Materials and Methods: We retrospectively reviewed medical records of 90 consecutive patients who underwent hip arthroscopy from January 2017 to August 2019. Since August 2018, the analgesic protocol was changed from SI-FICB to SI-FICB with obturator nerve block. According to the analgesic regimen, patients were categorized as group N (no blockade), group F (SI-FICB only), and group FO (SI-FICB with obturator nerve block). Primary outcome was the cumulative opioid consumption at 24 hours after surgery. Additionally, cumulative opioid consumption at 6 and 12 hours after surgery, pain score, additional analgesic requests, intraoperative opioid consumption and hemodynamic stability, and postoperative nausea and vomiting were assessed. Results: Among 87 patients, there were 47 patients in group N, 21 in group F, and 19 in group FO. The cumulative opioid (fentanyl) consumption at 24 hours after surgery was significantly lower in the group FO compared with the group N (N: 678.5 (444.0-890.0) µg; FO: 482.8 (305.8-635.0) µg; p = 0.014), whereas the group F did not show a significant difference (F: 636.0 (426.8-803.0) µg). Conclusion: Our findings suggest that implementing obturator nerve block into SI-FICB can reduce postoperative opioid consumption in hip arthroscopy.

The frequency of reduction loss after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device, and its effect on clinical and radiological results.

BACKGROUND: The aim of this study was to investigate the effect of reduction loss of more than 3 mm on clinical and radiological results after at least 2 years of follow-up after arthroscopic fixation of acute acromioclavicular joint dislocations using a double-button device. METHODS: Thirty-six patients who had acute (< 3 weeks old), type III or V acromioclavicular (AC) joint dislocations underwent arthroscopic fixation of the AC joint using a double-button device. Clinical and radiological evaluations were performed at preoperative, postoperative first day, 3 months and last follow-up. When the coracoclavicular (CC) distances of patients at the last follow-up were compared to the early postop CC distances, those with a difference of 3 mm or less were grouped as group A and those with a difference of more than 3 mm were grouped as group B. RESULTS: There was no statistically significant difference between the groups in terms of age, gender, follow-up time, time from injury to surgery, return to work, and distribution of Rockwood classification. Pre-operative CC distance was reduced from 18.7 ± 3.5 to 8.5 ± 0.6 in the early postoperative period. Anatomic reduction was achieved in all patients compared with the unaffected side (CC distance 8.6 ± 0.7). However, the CC distance increased to 9.9 ± 1.5 at the third-month follow-up and increased to 11 ± 2.7 at the last follow-up. There were no significant Constant score differences between the groups in the preoperative and last follow-up periods (p > 0.05). At the last follow-up, the mean Acromioclavicular Joint Instability (ACJI) score of group A was 84.4 ± 8, whereas it was 68.3 ± 8.3 for group B, and the difference was statistically significant (p < 0.01). Furthermore, the subjective evaluation and aesthetic subjective satisfaction values of group B were lower than group A (p < 0.01). CONCLUSIONS: Reduction loss of more than 3 mm was observed in 25% of patients after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device. Although this loss did not create a statistically significant difference in Constant scores, AC joint-specific tests such as ACJI, subjective evaluation, and aesthetic subjective satisfaction values were significantly impaired.

Expanding Indications for Meniscal Repair.

Meniscus surgery has dramatically changed over the last 20 years. This article reviews the advances and current evidence in meniscus repair.

Decreasing the number of arthroscopies in knee osteoarthritis - a service evaluation of a de-implementation strategy.

BACKGROUND: The Personalised Knee Improvement Programme (P-KIP) was developed based on previously published work, with the hypothesis that surgeons would refer patients to a well-structured conservative management intervention instead of for arthroscopy (de-implementation of arthroscopy by substitution with P-KIP). This meets NICE guidelines and international recommendations but such programmes are not widely used in the UK. Our aim was to determine whether P-KIP would reduce the number of arthroscopies performed for knee osteoarthritis. METHODS: P-KIP is a conservative care pathway including a group education session followed by individually tailored one-to-one dietician and physiotherapy sessions. Virtual clinic follow-up is conducted three to 6 months after completion of the programme. The service began in July 2015. The number of arthroscopies saved, measured from hospital level coding data, is the primary outcome measure. Interrupted time series analysis of coding data was conducted. As a quality assurance process, patient reported outcome measures (Oxford Knee Score; Euroqol 5D) were collected at baseline and at follow up. RESULTS: Time series analysis demonstrates that the programme saved 15.4 arthroscopies a month (95% confidence interval 9-21; p < 0.001), equating to 184 arthroscopies a year in a single hospital. The PROMs data demonstrated improvements in patient reported outcome scores consistent with previous published reports of conservative interventions in similar patient populations. CONCLUSIONS: Results suggest that P-KIP reduces the number of arthroscopies performed, and patients who took part in P-KIP had an improvement in their knee and general health outcomes. P-KIP has the potential to deliver efficiency savings and relive pressure on operative lists, however replication in other sites is required.

The changing incidence of arthroscopic subacromial decompression in Scotland.

AIMS: The aim of this study was to examine the recent trend in delivery of arthroscopic subacromial decompression (ASD) in Scotland and to determine if this varies by geographical location. METHODS: Scottish Morbidity Records were reviewed retrospectively between March 2014 and April 2018 to identify records for every admission to each NHS hospital. The Office of Population Censuses and Surveys (OPCS-4) surgical codes were used to identify patients undergoing primary ASD. Patients who underwent acromioclavicular joint excision (ACJE) and rotator cuff repair (RCR) were identified and grouped separately. Procedure rates were age and sex standardized against the European standard population. RESULTS: During the study period the number of ASDs fell by 649 cases (29%) from 2,217 in the first year to 1,568 in the final year. The standardized annual procedure rate fell from 41.6 (95% confidence interval (CI) 39.9 to 43.4) to 28.9 (95% CI 27.4 to 30.3) per 100,000. The greatest reduction occurred between 2017 and 2018. The number of ACJEs rose from 41 to 188 (a 3.59-fold increase). The number of RCRs fell from 655 to 560 (-15%). In the year 2017 to 2018 there were four (28.6%) Scottish NHS board areas where the ASD rate was greater than 3 standard deviations (SDs) from the national average, and two (14.3%) NHS boards where the rate was less than 3 SDs from the national average. CONCLUSION: There has been a clear decline in the rate of ASD in Scotland since 2014. Over the same period there has been an increase in the rate of ACJE. The greatest decline occurred between 2017 and 2018, corresponding to the publication of epidemiological studies demonstrating a rise in ASD, and awareness of studies which questioned the benefit of ASD. This paper demonstrates the potential impact of information from epidemiological studies, referral guidelines, and well-designed large multicentre randomized controlled trials on clinical practice. Cite this article: Bone Joint J 2020;102-B(3):360-364.

The Superior Capsular Reconstruction: Lessons Learned and Future Directions.

The ideal solution for the irreparable rotator cuff tear remains in question. A recent innovative technique, superior capsular reconstruction (SCR), has demonstrated promising results with some early clinical outcomes demonstrating statistically notable improvements in active forward flexion and American Shoulder and Elbow Surgeons scores. Multiple biomechanical studies have also demonstrated its ability to reduce superior translation of the humerus after massive rotator cuff tear. Even so, these results are still early and durability of the reconstruction over time needs to be determined. Although more than 15,000 SCRs have been done worldwide, there remains a paucity of outcome data and one must be vigilant to not allow enthusiasm to overtake critical evaluation. The potential mechanisms of action, including tenodesis effect, force coupler, or subacromial spacer, need further elucidation and the ideal indications for this procedure, as well as its technical optimization, and limitations have yet to be fully determined. The purpose of this review is to critically evaluate the biomechanical and clinical literature that has assessed SCR, along with the controversies and considerations encountered with this procedure.

The Evolution of Hip Arthroscopy: What Has Changed Since 2008-A Single Surgeon's Experience.

PURPOSE: To compare a single surgeon's first 200 cases of hip arthroscopy with the last 200 cases regarding patient demographic characteristics, indications for surgery, intraoperative findings, procedures performed, and patient-reported outcomes. METHODS: Data were reviewed for all patients undergoing primary hip arthroscopy between February 2008 and August 2016 performed by a single surgeon. Of the 3,319 patients who underwent hip-preservation surgery during the study period, the first 200 (group A) and last 200 (group B) eligible for minimum 2-year follow-up were included in our analysis. RESULTS: Follow-up was available for 187 of 200 patients (93.5%) and 189 of 200 patients (94.5%) in groups A and B, respectively. The groups were similar in age, sex, and body mass index (P > .05). Group A included significantly more patients with Tönnis grade 1 (37% vs 21%, P < .001). Group B consisted of significantly more (P < .001) labral reconstructions (10.2% vs 0%), capsular closures (72.7% vs 26.2%), and gluteus medius repairs (18.2% vs 3.2%). Femoroplasty was performed for smaller cam lesions in group B, resulting in smaller postoperative alpha angles (45.7° ± 7.9° vs 42.4° ± 6.3°, P < .001). Group B exhibited significantly higher patient-reported outcomes at minimum 2-year follow-up (P < .05). In addition, in group B, greater proportions of patients achieved the minimal clinically important difference and patient acceptable symptomatic state (P < .05). CONCLUSIONS: This study shows the noteworthy evolution in the management of the prearthritic adult hip occurring between 2008 and 2016. This includes improvements in preoperative patient evaluation and patient selection. In addition, the proportion of patients undergoing labral reconstruction, capsular plication, and femoroplasty has increased significantly. These developments, as well as increased surgical experience, may have contributed to improved surgical outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

National trends in the diagnosis and repair of SLAP lesions in the United States.

BACKGROUND: Since superior labrum anterior-to-posterior (SLAP) tear was introduced as an International Classification of Diseases-Ninth Revision, Clinical Modification diagnosis in 1994, awareness, diagnosis, and surgical treatment of this disorder has increased. Here, we aim to clarify trends in the frequency of SLAP tear diagnosis and arthroscopic SLAP repair surgery in the United States. METHODS: Using private insurance claims from 2003 to 2013 in MarketScan (approximately 55 million Americans), we identified patients with SLAP tear diagnosis or arthroscopic SLAP repair surgery. Population-based rates of SLAP diagnosis and related shoulder procedures were calculated. RESULTS: A total of 329,643 patients in the MarketScan database received a SLAP tear diagnosis. In all, 62.8% underwent some form of shoulder surgery after diagnosis. SLAP diagnosis increased from 28.0 per 100,000 in 2003 to 142.4 per 100,000 in 2013 (p < 0.0001); the rate of shoulder surgery in these patients increased from 20.1 per 100,000 in 2003 to 74.1 per 100,000 in 2013 (p < 0.0001). However, the percentage of patients with SLAP tears who got shoulder surgery decreased (p < 0.0001). In 2003, almost no patient got biceps tenodesis for SLAP tears; by 2013, 18.1% of surgeries for SLAP tear were biceps tenodesis. Isolated arthroscopic SLAP repairs peaked in 2009 at 28.4 per 100,000 and stabilized thereafter. CONCLUSION: We confirmed prior reports that SLAP diagnosis increased from 2003 to 2013, although the percentage of these patients who underwent surgery decreased over this period. Arthroscopic SLAP repair doubled but then plateaued after 2009. Biceps tenodesis now accounts for a substantial portion of surgeries for SLAP tear. This may reflect an improved understanding of superior labrum anatomy and biomechanics.