The abundant vascular structures that surround the shoulder joint are complex and variable, complicating arthroscopy approaches. The aim of this study is to determine safe and risky areas around ...standard posterior and standard anterior portals, and accounting for the distribution of neurovascular structures of small and medium diameters that can lead to intra-articular bleeding during surgery. The standard posterior portal, and standard anterior portal were placed as described in the literature, and punch dissection was performed 2.5 cm around the trocar in situ. The arrangement of each identified structure was photographically documented and digitalized for each anatomic plane; the distance to the trocar and the diameter of each structure were measured. Based on each digitalized anatomic plane, safe and risky tissue areas were determined, and a clock face coordinate system was used to represent these areas. The safe area around the standard posterior portal was located between 11 and 1 o'clock for the left shoulder and 11 and 2 o'clock for the right shoulder. For the standard anterior portal, the safe area was located between 2 and 3 o'clock for the left shoulder and between 9 and 12 o'clock for the right shoulder. However, we did document a risk of injuring the cephalic vein 5 times, the axillary artery 3 times and the deltoid branch of the thoracoacromial artery once. This study reports quantitatively the total number of small diameter structures present in the two shoulder arthroscopic portals evaluated. The safe areas proposed in this study must be evaluated to propose new access points for performing arthroscopic procedures on the shoulder. KEY WORDS: Anatomy; Arthroscopy; Portals; Safe Areas; Shoulder. Las abundantes estructuras vasculares que rodean la articulacion del hombro son complejas y variables, y dificultan los abordajes artroscopicos. El objetivo del estudio fue determinar areas seguras y en riesgo en relacion al portal posterior estandar y el portal anterior estandar y cuantificar la distribucion de estructuras de diametro pequeno e intermedio que puedan conducir a sangrado intraarticular durante la cirugia. El portal posterior estandar y el portal anterior estandar fueron colocados segun su descripcion en la literatura y fueron realizadas disecciones en sacabocado de 2,5 cm alrededor del trocar in situ. La disposicion de cada estructura identificada fue documentada fotograficamente y digitalizada para cada plano anatomico. La distancia hacia el trocar y el diametro de cada estructura fueron medidos. Basado en cada plano anatomico digitalizado, areas de seguridad y riesgo tisular fueron determinadas y un sistema de coordenadas de manecillas de reloj fue utilizado para representar estas areas. El area segura alrededor del portal posterior estandar fue localizada entre las 11 y las 1 en el sistema de las manecillas del reloj para hombros izquierdos y entre las 11 y las 2 para hombros derechos. Para el portal anterior estandar, el area segura fue localizada entre las 2 y 3 horas para hombros izquierdos y entre las 9 y 12 horas para hombros derechos. Aun asi, se documento el riesgo de lesionar la vena cefalica en 5 ocasiones, la arteria axilar en 3 ocasiones y la rama deltoidea de la arteria toracroacromial en una ocasion. Este estudio reporta cuantitativamente el numero total de estructuras de pequeno diametro presentes en los dos portales artroscopicos evaluados. Las areas seguras propuestas en este estudio deben ser evaluadas para proponer nuevos puntos de acceso para la realizacion de procedimientos artroscopicos en el hombro. PALABRAS CLAVE: Anatomia; Artroscopia; Portales; Areas Seguras; Hombro.
The abundant vascular structures that surround the shoulder joint are complex and variable, complicating arthroscopy approaches. The aim of this study is to determine safe and risky areas around ...standard posterior and standard anterior portals, and accounting for the distribution of neurovascular structures of small and medium diameters that can lead to intra-articular bleeding during surgery. The standard posterior portal, and standard anterior portal were placed as described in the literature, and punch dissection was performed 2.5 cm around the trocar in situ. The arrangement of each identified structure was photographically documented and digitalized for each anatomic plane; the distance to the trocar and the diameter of each structure were measured. Based on each digitalized anatomic plane, safe and risky tissue areas were determined, and a clock face coordinate system was used to represent these areas. The safe area around the standard posterior portal was located between 11 and 1 o'clock for the left shoulder and 11 and 2 o'clock for the right shoulder. For the standard anterior portal, the safe area was located between 2 and 3 o'clock for the left shoulder and between 9 and 12 o'clock for the right shoulder. However, we did document a risk of injuring the cephalic vein 5 times, the axillary artery 3 times and the deltoid branch of the thoracoacromial artery once. This study reports quantitatively the total number of small diameter structures present in the two shoulder arthroscopic portals evaluated. The safe areas proposed in this study must be evaluated to propose new access points for performing arthroscopic procedures on the shoulder.
Abstract Since the introduction of the beach chair position for shoulder arthroscopy, orthopaedic surgeons have debated whether the beach chair or lateral decubitus is superior. Most surgeons use the ...same patient position to perform all of their arthroscopic shoulder procedures, regardless of the pathology. Each position has its advantages and disadvantages. The evidence regarding the efficiency, efficacy, and risks of the lateral decubitus and the beach chair positions for shoulder arthroscopy does not show one position to be superior. This review presents a comparison of these positions with regard to setup, surgical visualization, access, and patient risk.
Background:
The use of posterior ankle and hindfoot arthroscopy (PAHA) has been expanding over time. Many new indications have been reported in the literature. The primary objective of this study was ...to report the rate of PAHA complication in a large cohort of patients and describe their potential associations with demographical and surgical variables.
Methods:
In this IRB-approved retrospective comparative study, patients who underwent posterior ankle and/or hindfoot arthroscopy in a single institution from December 2009 to July 2016 were studied. Three fellowship-trained orthopaedic foot and ankle surgeon performed all surgeries. Demographic data, diagnosis, tourniquet use, associated procedures, and complications were recorded. To investigate a priori factors predictive of neurologic complication after PAHA, univariate and multivariable logistic regression was utilized. Where appropriate, sparse events sensitivity analysis was tested by fitting models with Firth log-likelihood approach.
Results:
A total of 232 subjects with 251 surgeries were selected. Indications were posterior ankle impingement (37%), flexor hallux longus disorders (14%), subtalar arthritis (8%), and osteochondral lesions (6%). Complications were observed in 6.8% (17/251) of procedures. Neural sensory lesions were noted in 10 patients (3.98%), and wound complications in 4 ankles (1.59%). Seven neurologic lesions resolved spontaneously and 3 required further intervention. In a multivariable regression model controlled for confounders, the use of accessory posterolateral portal was the significant driver for neurologic complications (odds ratio OR 32.19, 95% CI 3.53-293.50).
Conclusion:
The complication rate in this cohort that was treated with posterior ankle and/or hindfoot arthroscopy was 6.8%. Most complications were due to neural sensorial injuries (sural 5, medial plantar nerve 4, medial calcaneal nerve 1 ) and 3 required additional operative treatment. The use of an accessory posterolateral portal was significantly associated with neurologic complications. The provided information may assist surgeons in establishing diagnoses, making therapeutic decisions, and instituting surgical strategies for patients that might benefit from a posterior arthroscopic approach.
Level of Evidence:
Level III, retrospective comparative study.
Background:
Femoroacetabular impingement (FAI) has become a more commonly recognized cause of limited hip range of motion and hip pain among young adults and athletes. Hip arthroscopy is recommended ...for the surgical treatment of this disorder, unless specific contraindications exist. Despite the increasing rate of published studies in this area, there remains no aggregate data for outcomes after this approach.
Purpose:
To evaluate risk factors and outcomes after arthroscopic management of FAI, including return to play, revision rate, surgical and nonsurgical complications, change in α-angle, intraoperative bone resection, and patient-reported outcomes.
Study Design:
Meta-analysis and systematic review.
Methods:
A review of the current literature was performed with the terms “femoroacetabular impingement,” “hip arthroscopy,” and numerous variations thereof in PubMed, EMBASE, BioMed Central, Cochrane, Science Direct, and Scopus, yielding 1723 abstracts. After screening by eligibility criteria, 31 articles were included. The incidence of bilateral FAI was determined by enrollment data, and pooled estimates were calculated for postoperative patient-reported outcome measures, α-angles, return to sport, postoperative complications, and reoperation risk.
Results:
A total of 1981 hips among 1911 patients were identified, with a mean ± SD age of 29.9 ± 1.9 years and 29.5 ± 14.0 months of follow-up. The incidence of bilateral FAI in these studies that required operative intervention was 3.6%. The pooled risk of reoperation after hip arthroscopy, including revision surgery or subsequent total hip arthroplasty, was 5.5% (95% CI, 3.6%-7.5%). The risk of clinical complications was 1.7% (95% CI, 0.9%-2.5%). In total, 87.7% of patients demonstrated return to sport after surgery (95% CI, 82.4%-92.9%, P < .001), and all patient-reported outcomes improved postoperatively, with the highest increase observed in the Hip Outcome Score sports scale (41.7 points; 95% CI, 34.1-49.4; P < .001). The α-angle decreased by an average of 23.6° (95% CI, 18.2°-29.0°; P < .001). We identified 11 factors associated with the success of hip arthroscopy in FAI and 16 factors associated with failure or negative outcomes.
Conclusion:
A high percentage of patients return to sport activities after hip arthroscopy for FAI, with a low rate of complications and reoperation. All patient-reported outcome measures, except for mental health, significantly improved after surgery.
Hip arthroscopy is a fast-growing and evolving field. Like knee and shoulder arthroscopy, hip arthroscopy began as a diagnostic procedure and then progressed to biopsy and resection of abnormalities. ...Subsequently, it has evolved to repair of various tissues and treatment of underlying causes. As the understanding of the hip joint and its associated pathophysiology grows, indications will continue to expand for this diagnostic and therapeutic modality. This article outlines the historic developments of hip arthroscopy, including advancements in instrumentation and techniques from the days of the first hip arthroscopies to the present day.
This review explores the current literature regarding both the clinical indications and utility of minimally invasive in-office needle arthroscopy (IONA) relative to conventional imaging modalities.
...In compliance with R-AMSTAR (Revised Assessment of Multiple Systematic Reviews) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, 3 databases (MEDLINE, Embase, and PubMed) were searched in July 2018, in addition to the conference abstract databases of 5 prominent meetings between 2013 and 2018, for studies using IONA for diagnostic purposes. Study quality was assessed with the Methodological Index for Non-Randomized Studies (MINORS) criteria.
Among 932 conference abstracts and 369 studies identified, 11 publications involving 404 patients (395 knees and 9 shoulders) were included, with 9 clinical studies and 2 cost analyses. The median Methodological Index for Non-Randomized Studies (MINORS) score was 9 for noncomparative and 23 for comparative studies. Among the 9 clinical studies, IONA had a superior sensitivity, specificity, positive predictive value, and negative predictive value to magnetic resonance imaging (MRI) in the evaluation of knee osteoarthritis, anterior cruciate ligament insufficiency, and meniscal tears. IONA was comparable or inferior to MRI in the same parameters for the diagnosis of osteochondral defects and rotator cuff tears. In the 2 cost analyses, IONA had lower costs when used in place of MRI for treatment algorithms involving medial meniscal tears and rotator cuff tears but not lateral meniscal tears.
IONA holds potential for cost savings and improved diagnostic accuracy relative to MRI, primarily for intra-articular meniscal, ligamentous, and chondral defects of the knee. However, its current indications for use in other joints are limited to rotator cuff tears in the shoulder, making its diagnostic value in other joints much more limited. The current quality and breadth of evidence are significantly lacking, with numerous practical shortcomings. To improve acceptance of IONA, priority should be placed on establishing defined protocols, indications, contraindications, and patient perspectives for the procedure.
Level IV, systematic review of Level II, III, and IV studies.
Background:
There is minimal information available on the threshold at which patients consider themselves to be well for patient-reported outcome measures used in patients treated with hip ...arthroscopy for femoroacetabular impingement (FAI).
Purpose:
To determine the patient acceptable symptomatic state (PASS) for the modified Harris Hip Score (mHHS) and the Hip Outcome Score (HOS) in patients with FAI treated with arthroscopic hip surgery.
Study Design:
Cohort study (diagnosis); Level of evidence, 2.
Methods:
A consecutive series of patients at a single institution with FAI who were treated with arthroscopic labral surgery, acetabular rim trimming, and femoral osteochondroplasty were eligible. The mHHS (score range, 0-100) and the HOS (score range, 0-100) were administered at baseline and at 12 months postoperatively. An external anchor question at 1 year postoperatively was utilized to determine PASS values: “Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?”
Results:
There were 130 patients (mean ± SD age, 35.6 ± 11.7 years), and 42.3% were male. Based on a receiver operator curve analysis, the PASS values—at which patients considered their status to be satisfactory—at 1 year after surgery were 74 (mHHS), 87 (HOS–activities of daily living subscale), and 75 (HOS–sports subscale). The PASS threshold was not affected by baseline scores across different instruments. However, patients with higher baseline scores were more likely to achieve the PASS (odds ratios: 3.36 mHHS, 3.83 HOS–activities of daily living, 3.38 HOS-sports). Age and sex were not significantly related to the odds of achieving the PASS for the mHHS or the HOS.
Conclusion:
This is the first study to determine the PASS for 2 commonly used hip joint patient-reported outcome measures in patients undergoing surgery for FAI. The study findings can allow researchers to determine if interventions related to FAI are meaningful to patients at the individual level across various domains and will also be useful for responder analyses in future randomized trials related to hip arthroscopy and the treatment of FAI.
PDF
