Abstract Purpose There is a lack of a clear, uniform definition for intraoperatively assessed component loosening of a knee arthroplasty component, complicating the interpretation and ...interchangeability of results of diagnostic studies using an intraoperative observation as the reference test. The purpose of this study was to establish a consensus among specialised knee revision surgeons regarding the definition of intraoperatively determined loosening of total or unicondylar knee arthroplasty components. Methods Utilising the Delphi consensus method, an international panel of highly specialised knee revision surgeons was invited to participate in a three‐round process. The initiation of the first round involved the exploration of possible criteria for intraoperatively determined loosening with open questions. The second round focused on rating these criteria importance on a five‐point Likert scale. For the third round, criteria that reached consensus were summarised in consecutive definitions for intraoperatively determined loosening and proposed to the panel. Consensus was established when over 70% of participants agreed with a definition for intraoperatively determined loosening. Results The 34 responding panel members described in total 60 different criteria in the first round of which 34 criteria received consensus in the second round. Summarising these criteria resulted in four different definitions as minimal requirements for intraoperatively determined loosening. Eighty‐eight percent of the panel members agreed on defining a component as loose if there is visible fluid motion at the interface observed during specific movements or when gently applying direct force. Conclusion This study successfully established a consensus using a Delphi method among knee revision surgeons on the definition of intraoperatively determined component loosening. By agreeing on the visibility of fluid motion as new definition, this study provides a standardised reference for future diagnostic research. This definition will enhance the interpretability and interchangeability of future diagnostic studies evaluating knee arthroplasty component loosening. Level of Evidence Level V.
Both acute and chronic syndesmotic injuries are associated with (osteo)chondral lesions of the ankle in at least 1 out of 5 patients. Having a common denominator of an acute traumatic injury being ...external rotation and forced dorsiflexion, the injury of a combined unstable syndesmotic injury and a potentially present concomitant (osteo)chondral lesion to the ankle warrants a thorough diagnostic and interventional approach. Furthermore, early diagnosis may prevent further damage to the joint through lifestyle changes and increase the chances of successful conservative or surgical treatment, potentially reducing the progression toward end-stage osteoarthritis. Consequently, technological advances and financial considerations have led to the development of a minimally invasive needle arthroscopic inspection and treatment of concomitant (osteo)chondral injuries of the ankle in the combined treatment of unstable syndesmotic injuries with suture button fixation. The present Technical Note describes this innovative minimally invasive assessment and concomitant treatment technique.
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Cartilage and osteochondral lesions of the first metatarsophalangeal (MTP-1) joint are characterized by pain during weight bearing and walking. The lesions often require surgical intervention(s). ...Arthroscopic bone marrow stimulation may be considered the preferred operative intervention for small lesions. Technological advances, patient preferences, and economic considerations combine to foster the development of minimally invasive needle arthroscopic procedures. This technical note presents and highlights our minimally invasive surgical technique for needle arthroscopic treatment through bone marrow stimulation for osteochondral lesions of the MTP-1 joint.
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ObjectivesThis study aimed to determine the incidence rate and characterise the location and severity of cartilage lesions in the ankle in elite athletes undergoing suture-button stabilisation for ...unstable distal syndesmotic injuries using needle arthroscopic examination. The feasibility and safety of ad hoc needle arthroscopy and its assisted interventions were also assessed.MethodsThis prospective case series included elite athletes undergoing surgical stabilisation between April 2021 and June 2023. Procedures involved suture button fixation and needle arthroscopy, conducted by a single ankle fellow-trained surgeon. Ankle cartilage lesions were graded using the Cheng and Ferkel classification and located using the nine-zone grid. The study followed the STROBE statement.ResultsThis study included 16 elite athletes undergoing surgery for distal syndesmotic injuries, with 75% having acute and 25% chronic injuries. Cartilage lesions were prevalent (n=15/16, 94%), mainly at the talar dome (90%), and primarily scored as grade 1 (33%) or grade 2 (67%). Distal tibia cartilage damage occurred in 13% of cases. All patients were diagnosed with an instability of the syndesmosis confirmed through needle arthroscopy and were treated with a suture button (one or two buttons) fixation.ConclusionIn 15/16 elite athletes with syndesmotic injuries, concomitant ankle cartilage lesions were identified through needle arthroscopy. In addition, most of the lesions were classified as grade 1 or 2, denoting superficial damage. Needle arthroscopic interventions proved feasible and safe for confirming syndesmotic instability and addressing intra-articular pathologies.
Introduction
Most adult cases of bacterial–septic–arthritis of a native joint are effectively managed with a single surgical debridement, but some cases may require more than one debridement to ...control the infection. Consequently, this study assessed the failure rate of a single surgical debridement in adults with bacterial arthritis of a native joint. Additionally, risk factors for failure were assessed.
Materials and Methods
The review protocol was registered on PROSPERO (CRD42021243460) before data collection and conducted in line with the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ (PRISMA) guidelines. Multiple libraries were systematically searched to identify articles including patients reporting on the incidence of failure (i.e. persistence of infection requiring reoperation) of the treatment of bacterial arthritis. The quality of individual evidence were assessed using the Quality in Prognosis Studies (QUIPS) tool. Failure rates were extracted from included studies and pooled. Risk factors for failure were extracted and grouped. Moreover, we evaluated which risk factors were significantly associated with failure.
Results
Thirty studies (8,586 native joints) were included in the final analysis. The overall pooled failure rate was 26% (95% CI 20 to 32%). The failure rate of arthroscopy and arthrotomy was 26% (95% CI 19 to 34%) and 24% (95% CI 17 to 33%), respectively. Seventy-nine potential risk factors were extracted and grouped. Moderate evidence was found for one risk factor (synovial white blood cell count), and limited evidence was found for five risk factors (i.e. sepsis, large joint infection, the volume of irrigation, blood urea nitrogen-test, and blood urea nitrogen/creatinine ratio).
Conclusion
A single surgical debridement fails to control bacterial arthritis of a native joint in approximately a quarter of all adult cases. Limited to moderate evidence exists that risk factors associated with failure are: synovial white blood cell count, sepsis, large joint infection, and the volume of irrigation. These factors should urge physicians to be especially receptive to signs of an adverse clinical course.
Over the years, possibilities in ankle arthroscopy have evolved from diagnostic inspection to complex interventional procedures. Further innovation may come from needle arthroscopy, which has ...improved substantially in image quality in recent years and can now be used for interventional procedures as well. We here present a standardized approach to wide-awake needle arthroscopy of the anterior ankle under local anesthesia. As new needle arthroscopic procedures of the ankle arise, this approach serves to help ensure safe, uniform, and beneficial adoption of this emergent technique.
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Suspected bacterial arthritis of a native joint requires urgent management to control potential life-threatening sepsis and limit cartilage damage. Diagnosing bacterial arthritis is often challenging ...and relies on diagnostic tests with low accuracy. A high threshold for surgery poses a risk of undertreatment, whereas a low threshold for surgery could lead to overtreatment with unnecessary invasive and costly procedures. Surgical lavage through arthroscopy or arthrotomy is generally considered standard treatment. Nowadays, needle arthroscopy provides an alternative and potentially less-invasive approach that can safely lower the surgical threshold. Needle arthroscopy can be performed directly upon presentation at the patient's bedside, as it is well tolerated under local anesthesia. Therefore, this Technical Note presents a stepwise guideline for performing standardized needle arthroscopic lavage in patients with (suspected) bacterial arthritis of the shoulder, elbow, wrist, knee, and ankle.
Video 1
The surgical technique of the needle arthroscopy for each joint. Patient setup, anatomical landmarks, and the inflow and outflow portals are clarified per joint. The surgical technique of the shoulder starts at 0:48 minutes, the elbow at 1:31 minutes , the wrist at 2:17 minutes , the knee at 2:54 minutes , and the ankle at 3:41 minutes.
Purpose
The literature presents a wide range of success rates for a single surgical intervention of bacterial‐septic‐arthritis, and there is a lack of clear criteria for identifying treatment failure ...and making decisions about reintervention. This Delphi study aims to establish a consensus among an international panel of experts regarding the definition of treatment failure and the criteria for reintervention in case of bacterial arthritis.
Methods
The conducting and reporting Delphi studies (CREDES) criteria were used. Data from a systematic review was provided as the basis for the study. A list of 100 potential experts were identified. The study was designed and conducted as follows: (I) identification and invitation of an expert panel, (II) informing the participating expert panel on the research question and subject, and (III) conducting two or three Delphi rounds to reach consensus on explicit research items. Potential criteria were rated on a five‐point Likert scale.
Results
Sixty orthopaedic experts from nine countries participated in this Delphi study, with 55 completing all three rounds. The mean experience as an orthopaedic surgeon was 15 years (SD ± 9). Strong (96%) consensus was reached on the definition of treatment failure: the persistence of physical signs of arthritis (e.g., pain and swelling) and/or systemic inflammation (e.g., fever and no improvement in CRP) despite surgical and antibiotic treatment. Furthermore, consensus (>80%) was reached on six criteria influencing the decision for reintervention; pain (81%), sepsis (98%), fever (88%), serum CRP (93%), blood culture (82%), and synovial fluid culture (84%).
Conclusion
The definition of treatment failure for bacterial arthritis after a single surgical intervention was established through a three‐round Delphi study. Additionally, consensus was reached on six criteria that are helpful for determining the need for reintervention. This definition and these criteria may help in the development of clinical guidelines, and will empower physicians to make more precise and consistent decisions regarding reintervention for patients, ultimately aiming to reduce over‐ and undertreatment and improve patient outcomes.
Level of Evidence
Level V.
To compare cartilage quality after different surgical interventions for osteochondral lesions of the talus (OLT), evaluated by second-look arthroscopy. Secondary aims were to report concomitant ...diagnoses, and to correlate cartilage quality with clinical and radiological outcomes. This review hypothesizes that the cartilage repair after bone marrow stimulation (BMS) is inferior to the other available treatment options.
PROSPERO ID: CRD42022311489. Studies were retrieved through PubMed, EMBASE (Ovid), and Cochrane Library. Studies were included if they reported cartilage quality after second-look investigation after surgical treatment of OLT. The primary outcome measure was the cartilage quality success and failure rates (%) per surgical intervention group. Correlations between the cartilage quality and clinical or radiological outcomes were calculated.
Twenty-nine studies were included, comprising 586 ankles that had undergone second-look arthroscopy on average 16 months after initial surgery. The success rate for BMS was 57% (95% confidence interval CI = 48%-65%), for fixation (FIX) 86% (95% CI = 70%-94%), for osteo(chondral) transplantation (OCT) 91% (95% CI = 80%-96%), for cartilage implementation techniques (CITs) 80% (95% CI = 69%-88%), and for retrograde drilling 100% (95% CI = 66%-100%). The success rate of BMS was significantly lower than FIX, OCT, and CIT (
< 0.01). There were no significant differences between other treatment groups. A moderate positive significant correlation between the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society score (ICRS) was found (ρ = 0.51,
< 0.001).
Successful restoration of cartilage quality was found in the majority of surgically treated OLTs. However, BMS yields inferior cartilage quality compared with FIX, OCT, and CIT.
Systematic review and meta-analysis.
Level IV, systematic review and meta-analysis.
Bacterial arthritis in paediatrics is a potentially devastating disease. It can cause permanent damage to the joint leading to degenerative changes, possible growth deformities or failure, and might ...even result in death. An arthrotomy allows for sufficient irrigation. It might however lead to increased iatrogenic damage and unesthetic scarring. A new technical innovation, so-called needle arthroscopy, might reduce these side effects. The purpose of this case series is to show the safety and efficacy of the use of the 1.9-mm needle arthroscopic lavage in the management of neonates and infants with bacterial arthritis. All three cases are successfully managed using needle arthroscopy.
