Glenohumeral osteoarthritis (OA) is a challenging clinical problem in young patients. Given the possibility of early glenoid component loosening in this population with total shoulder arthroplasty (TSA), and subsequent need for early revision, alternative treatment options are often recommended to provide pain relief and improved range of motion. While nonoperative modalities including nonsteroidal anti-inflammatory medications and physical therapy focusing on rotator cuff strengthening and scapular stabilization may provide some symptomatic relief, young patients with glenohumeral OA often need surgery for improved outcomes. Joint preserving techniques, such as arthroscopic debridement with removal of loose bodies and capsular release, with or without biceps tenotomy or tenodesis, remains a viable nonarthroplasty option in these patients. Clinical studies evaluating the outcomes of arthroscopic debridement for glenohumeral OA in young patients have had favorable outcomes. Evidence suggests that earlier stages of glenohumeral OA have more favorable outcomes with arthroscopic debridement procedures, with worse outcomes being observed in patients with complete joint space loss and bipolar chondral lesions. More advanced arthroscopic options include inferior osteophyte excision and axillary neurolysis or microfracture of chondral lesions, both of which have demonstrated favorable early clinical outcomes. Patients with some preserved joint space and small osteophytes can avoid arthroplasty and have improved functional outcomes after arthroscopic debridement for glenohumeral OA. Caution should be advised when indicating this procedure for patients with large osteophytes, grade IV bipolar lesions, biconcave glenoids, and complete loss of joint space

Purpose. There is minimal information on outcome of glenohumeral debridement for treatment of shoulder osteoarthritis (OA). The purpose of this study was to examine the outcome of this procedure with or without acromioplasty /resection of clavicle in subjective perception of disability and functional range of motion and strength at one year following surgery. Method. Prospectively collected data of patients with advanced OA of the glenohumeral joint who were not good candidates for shoulder arthroplasty due to young age, high activity level, or desire to avoid major surgery at the time of assessment were included. Arthroscopic debridement included removal of loose bodies, chondral flaps, and degenerative tissue. Resection of the lateral end of the clavicle or acromioplasty was performed as clinically indicated for management of osteoarthritis of the Acromioclavicular (AC) joint or subacromial impingement respectively. Disability at 12 months following surgery was measured by the American Shoulder and Elbow Surgeons (ASES) assessment form, Constant-Murley score (CMS), strength, and painfree range of motion in four directions. Results. Sixty-seven patients (mean age= 57, SD: 15 (range: 25–87), range: 35–86, 35 females, 32 males) were included in analysis. The average symptom duration was 5 years. Fifteen (22%) patients had left shoulder involvement with 37 (55%) having right shoulder problem and 15(22%) reporting bilateral complaints. The right shoulder was operated on in 41 (61%) patients. Fifty two (78%) patients had an associated subacromial decompression [49 (73%) had acromioplasty and 27 (40%) had resection of the lateral end of the clavicle with some procedures overlapping]. Paired student t-tests showed a statistically significant improvement in scores of ASES and CMS (p<0.001) and painfree range of motion (p=0.02) at 1 year follow-up. However, no change was observed in strength (p>0.05). Conclusion. Arthroscopic debridement with or without acromioplasty /resection of the lateral end of the clavicle improves disability and painfree range of motion in patients suffering from osteoarthritis of glenohumeral joint at one year following surgery

From October 2005 to March 2014, we performed 46 arthroscopic surgeries for painful knee after knee arthroplasty. We excluded 16 cases for this study such as, unicompartmental knee arthroplasty, infection, patellar clunk syndrome, patellofemoral synovial hyperplasia, aseptic loosening, and follow-up period after arthroscopic surgery less than 6 months. Thirty cases matched the criteria. They had knee pain longer than 6 months after initial total knee arthroplasty (TKA), they had marked tenderness at medial and/or lateral tibiofemoral joint space, and also they complained walking pain with or without resting pain. Twenty one cases had initial TKA at our institute. In consideration of total number of TKA (n=489) in the period at our institute, incident rate of painful knee after initial TKA was 4.3%. Of 30 cases, 3 cases were male, and 27 cases were female. Types of implant were 4 in cruciate retaining type, 1 in cruciate substituting type, and 25 in posterior stabilized type. Age at the arthroscopy was 72 years old (51–87 years old), and period form initial TKA to pain perception was 18 months(1 – 144 months), and period from initial TKA to arthroscopic surgery was 29 months (6 – 125 months), and follow-up period after arthroscopy was 36 months (6 – 93 months). All arthroscopic debridement were performed through 3 portals, anteromedial, anterolateral, and proximal superomedial portal. Scar tissue impingements more than 5 mm wide were found in 87% of the cases both medial and lateral femorotibial joint spaces. Infrapatellar fat pad were covered with whitish scar tissue in all cases, and the scar tissue were connecting with the scar tissue which found at medial or lateral femorotibial joint spaces. We removed all scar tissue with motorized shaver or punches. At final follow-up, complete pain free in 63%, marked improvement in 3%, half improvement in 20%, slight improvement in 3%, and no change in 10% of the cases. Previously in the literatures, two reasons of the pain after total knee arthroplasty had been reported, patellar clunk syndrome, and patellar synovial hyperplasia. All cases reported this study had marked tenderness at tibiofemoral joint space. It was difficult to explain the tenderness by previously reported pathological mechanisms. We had to find another pathological mechanism to explain the pain of our cases. Painful knee due to scar tissue formation known as “infrapatellar contracture syndrome” after anterior cruciate ligament reconstruction surgery was previously reported. We hypothesized similar scar tissue formation should occur after TKA that caused painful knee. Continuity of the solid scar tissue between infrapatellar fat pad with the scar tissue at tibiofemoral joint space should be the cause of impingement at femorotibial joint even small size of scar tissue. From this study, we have to recognize that painful knee after TKA is not infrequent complication. And, if we could deny infection, and aseptic loosening in painful knee after TKA, arthroscopic debridement was good option to solve the pain. We could expect improvement of the pain more than half in 87% of cases

There are a variety of potential causes of shoulder arthritis in young patients including osteoarthritis, inflammatory arthritis, post-traumatic arthritis, and avascular necrosis. However, the primary etiology in my practice is related to complications of instability surgery or labral repair: thermal or anchor/suture related chondrolysis. The outcomes of arthroscopic debridement have been disappointing in patients with shoulder arthritis with worse results with increasing severity of articular cartilage changes. Among all joint arthroplasty procedures, patients who undergo shoulder arthroplasty have the youngest average age. Results of hemiarthroplasty (HA) have been approximately 75% to 80% compared to 90% with total shoulder arthroplasty (TSA). The largest series in the literature on shoulder arthroplasty in young patients is Schoch et al. They reviewed the results of 56 hemiarthroplasties and 19 TSA performed in patients less than 50 years old with a minimum 20-year follow-up or follow-up until reoperation. Both HA and TSA resulted in significant improvements in pain scores (p<0.001), abduction (p<0.01), and external rotation (p=0.02). Eighty-one percent of shoulders were rated much better or better than pre-operatively. Unsatisfactory ratings in HA were due to reoperations in 25 (glenoid arthrosis in 16) and limited motion, pain, or dissatisfaction in 11. Unsatisfactory ratings in TSA were due to reoperations in 6 (component loosening in 4) and limited motion in 5. Estimated 20-year survival was 75.6% (confidence interval, 65.9–86.5) for HAs and 83.2% (confidence interval, 70.5–97.8) for TSAs

Arthroscopy of ankle is becoming a common procedure for the diagnosis and treatment of ankle pain. Little information exists regarding the long term prognosis following ankle arthroscopy, particularly in avoiding further major surgery. The purpose of this study is to evaluate the prognosis of arthroscopic ankle treatment, based on survival analysis. Also we will formalise the relationship between the arthroscopic treatment and time for a further major ankle surgery.

Aim. The aim of this systematic review was to assess the existing published data on tuberculous arthritis involving native joints in adults aged 18 years and older. The specific research questions focused on the diagnosis and management of the disease. Method. This study was performed in accordance with the guidelines provided in the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). A systematic literature search was undertaken of Pubmed, Web of Science, Scopus and the Cochrane library. Only studies published in English since 1970 were considered. Case series involving less than 10 patients, systematic and narrative reviews, and laboratory or animal studies were excluded. We also excluded reports of TB infections not involving a “native joint” and tuberculosis of the spine. The level of evidence and strength of recommendations was performed in accordance with the GRADE system. Results. The systematic review of the literature yielded 2023 potential sources. Following deduplication, screening and full-text review, 20 data sources involving 573 patients from nine countries, were included. There was considerable variation amongst the studies in terms of the approach to diagnosis and management. The most common method used to confirm the diagnosis was microbiological culture of tissue obtained by biopsy, with positive findings in 93% of cases. Medical management involved a median 12 months of antitubercular treatment (IQR 8–16; range 4–18 months). Duration of pre-operative treatment ranged from two to 12 weeks in duration. Surgery was performed in approximately 87% of patients and varied from arthroscopic debridement to complete synovectomy combined with total joint arthroplasty. When arthroplasty and arthrodesis cases are excluded, 80% of patients received an open or arthroscopic debridement. The mean follow-up time of all studies was 26 months, with most studies demonstrating a minimum follow-up of at least six-months (range 3–112 months). Recurrence rates were reported in most studies, with an overall average recurrence rate of 7,4% (35 of 475). Conclusions. The current literature on TB arthritis highlights the need for the establishment of standardised diagnostic criteria. Further research is needed to define the optimal approach to medical and surgical treatment. The role of early debridement in active tuberculous arthritis needs to be explored further. Specifically, comparative studies are required to address the questions around use of medical treatment alone versus in combination with surgical intervention

Abstract. Objectives. The study aims to determine whether an arthroscopic ligament reconstruction is necessary to relieve clinical ankle instability symptoms in patients with an MRI scan showing medial or lateral ligament tear. Methods. This was a single centre retrospective case series study of 25 patients with ankle instability and ligament tear on MRI scan who had undergone arthroscopic procedures from January 2015 to December 2018. Patients were followed up for an average period of 3 years postoperatively to check for any recurrence of symptoms. Results. Of the 25 patients, 23 had ATFL tear on MRI scan, and 2 had deltoid ligament tear. Examination under anaesthesia was stable in 13 patients and unstable in 12 patients. The majority of the patients (76%) had a simple arthroscopic ankle debridement and no ligament repair. Six patients needed Brostrom repair. Conclusions. Our study has shown that in patients with MRI proven ligament tear and clinical instability, a ligament reconstruction was unnecessary in most patients. The instability symptoms of patients were relieved by simple ankle arthroscopic debridement

Infection is a potentially disastrous complication of total knee arthroplasty (TKA). Although advances in surgical technique and antibiotic prophylaxis have reduced the incidence of infection to approximately 1% in primary TKA, there is still a substantial number of patients. Treatment options include antibiotic suppression, irrigation and debridement with component retention (with or without polyethylene exchange), one-stage or two-stage revision, resection arthroplasty and rarely arthrodesis or amputation. Salvage of prostheses has always been associated with low rates of success. It was reported a success rate of 27% for open debridement. It is suitable for selective cases where infection occurs within the first 4–6 weeks of primary TKA or in the setting of acute hematogenous gram positive infection with stable implants. With the advances in arthroscopic technique, arthroscopy after TKA has become an accepted method to assess and manage the complications of TKA. Arthroscopic treatment for infected TKA was reported and the successful rate was similar or better than open debridement in selected situations. We used arthroscopic debridement combined with continuous antibiotic irrigation and suction to treat acute presentation of infected TKA with acceptable result. From 2010∼2013, we has performed arthroscopic debridement and continuous antibiotic irrigation system for seven patients with infected TKA. All of the seven patients had no open wounds nor sinuses and no radiological evidence of prosthetic instability or evidence of osteomyelitis. Most of the surgical intervention was performed within two weeks from the onset of symptoms. Arthroscopic debridement was performed with a shaver using a multiportal technique (anterolateral, anteromedial, superolateral, superomedial, posterolateral, posteromedial) and a continuous antibiotic irrigation system was used to dilutes concentration of the causative microorganism and keep high local bactericidal concentration of antibiotics. We evaluated the efficacy by using follow up of the C-reactve protein (CRP) test, erythrocyte sedimentation rate (ESR) test and physical examination. Successful treatment was defined as prosthesis retention without recurrent infection by the final follow-up. Six of seven infected TKA were cured without recurrence at a mean follow-up of 23 months (range, 6–41 months). One case with rheumatoid arthritis under long-term steroid therapy had recurred after episode of upper respiratory tract infection for 3 times. However, the infection was controlled by arthroscopic debridement and retention of the prosthesis was achieved. We emphasize the importance of posterior portal to ensure adequate arthroscopic debridement. It is imperative to make early diagnosis and treatment for infected TKA. We should make more effort to preserve the prosthesis in acute infection(within 2 weeks). With the advantage of minimal morbidity, arthroscopic treatement shoulder be an alternative to open debridement

Aim. Acute postoperative infection is reported to occur in 0.3–2% after arthroscopic rotator cuff repair. Few reports have addressed this dreaded complication although the costs are high both for the patient and for society. The aim of this prospective study was to describe incidence, treatment and outcome after acute postoperative infections following arthroscopic rotator cuff repair. Method. Patients undergoing arthroscopic rotator cuff repair in our department have been prospectively registered since 2009. 11 out of 1072 patients undergoing surgery developed an acute postoperative infection. The patients were examined with an MRI scan and/or functional scores (Constant Murley (CM) and WORC) at final follow-up. Results. All 11 patients that developed acute postoperative infections were male. Mean age was 54 (41–68) years. Except for male gender, no common underlying predisposing risk factor for infection could be identified. 1/11 patient had diabetes mellitus and 2/11 smoked. Average BMI was 27 (21–36). 1/11 was categorized as ASA 3 and the rest of the patients were ASA 1 and 2. All patients underwent arthroscopic debridement and biopsies were collected 26 (14–50) days after primary surgery. In 10 patients Propionibacterium acnes was cultured, and 6 of these patients also had positive cultures for coagulase negative staphylococci. In the remaining patient only coagulase negative staphylococcus was cultured. 5/11 patients were treated with one arthroscopic debridement, 5/11 had two arthroscopic debridements, whereas 1/11 required arthroscopic debridement four times before the infection was eradicated. Only 2/11 patients had to have their implants removed during the reoperation due to loosening of the suture anchors. All 11 patients were treated with parenteral antibiotics for 7–28 days, followed by oral treatment for 1–5 weeks, and all infections had resolved at final follow-up. Median CM score was 84 and median WORC score was 81% at follow-up median 22(11–28) months. 10 patients had a postoperative MRI scan after median 23 (3–49) months, 8 of them showing a healed cuff repair. Conclusions. Acute postoperative infections after arthroscopic rotator cuff repair can be eradicated with arthroscopic debridement(s) and removal of implants may not be necessary if patency is adequate. Despite the postoperative acute infection our patients presented good functional results and were satisfied at last follow-up

Aim. Arthroscopic interventions have revolutionized the treatment of joint pathologies. The appropriate diagnostics and treatment are required for infections after ligament reconstructions using non-resorbable material such as tendon grafts, anchors, and sutures, prone to biofilm formation. The infection rate is around 1% for knee and shoulder, while up to 4% for Achilles tendon reconstructions. Despite high number of these procedures worldwide, there is limited evidence about the best treatment protocol. Our study aimed to provide a general protocol for the treatment of small implants for soft tissue reconstruction. Method. Between 2019 and 2023, we treated 48 infections of ligament, meniscus, and tendon reconstructions out of 7291 related procedures performed in the same time period. Early infection (<30 days) were treated with an arthroscopic debridement and implant retention (DAIR), except Achilles tendons had open DAIR, while those with delayed or chronic infection (>30 days) were treated with extensive debridement and lavage combined with one-stage exchange (OSE) or implant removal. During surgery, at least 5 microbiological s and samples for histopathology were obtained. The removed material was sonicated. After surgery, all patients were one week on iv. antibiotics, followed by oral antibiofilm antibiotics for 6 weeks including rifampicin and/or a quinolone. All patients were followed for at least 1 year. Failure was defined as the need for additional revision surgery after finished iv. antibiotic treatment. Results. Among 48 patients, 38 were early and 10 were late acute or chronic infections. The incidence of infection for our cohort was 0.7%. We observed 27 infections after ligament reconstruction of the knee, 15 of the shoulder, 5 of the ankle, and 1 infection of the elbow joint. 40 patients were treated with DAIR, 5 with OSE, and 3 with implant removal. We had 11 C. acnes, 10 S. aureus, 6 S. epidermidis, 2 P. aeruginosa, 2 S. lugdunensis, 10 mixed flora, and 3 culture-negative infections. 12 patients received antibiotics before surgery, and all culture-negative infections were related to this subgroup. We observed 2 failures, both in a combination of proximal tibial osteotomy and ligament reconstruction of the knee joint. The success rate of our protocol was 96%. Conclusions. Prompt surgical treatment followed by 6 weeks of antibiotic treatment cured 96% of infections of small implants after reconstruction procedures of knee, shoulder, and ankle joints. Our study is the first to provide a treatment protocol for infections of small implants after ligament reconstruction procedures

Although cartilage repair has been around since the time of open Pridie drilling, clinical outcomes for newer techniques such as arthroscopic debridement, microfracture (MFX), osteochondral autograft transfers (OATS), osteochondral allograft transplantation and Autologous Chondrocyte Implantation (ACI) are still finding their place in treating injured knees. Early mechanical symptoms are best managed by a gentle arthroscopic debridement of loose articular flaps. This allows the surgeon to assess the defect size, location in the tibio-femoral or patellofemoral joint, status of the cartilage overall and patients response to the intervention. If the symptom improvement is not satisfactory to the patient, after assessing background factors that will influence the results of a cartilage repair procedure, (alignment of the patellofemoral joint or axial alignment, ligament stability and status of the meniscus), the surgeon can choose the best procedure for that individual based on the expected outcomes of the various cartilage repair techniques while addressing the background factors. As all the techniques have failures and informed discussion with the patient prior to performing the procedure is critical in avoiding disappointment for the patient and the surgeon. The repair technique used should incorporate considerations of the defect size, location, and the patient age, activity level, expectations and ability to comply with the longer rehabilitation needed for biological procedures as compared to prosthetic implants

Knee arthroscopy with debridement is commonly performed to treat osteoarthritis and degenerative meniscal tears in older adults; however robust evidence does not support sustained benefit from this procedure. Current Canadian guidelines advise against its use as first line treatment. Characterizing the use of this low value procedure will facilitate efforts to maximize quality of care, minimize harm and decrease healthcare costs. We sought to understand:. 1). the volume and variations of arthroscopic knee debridement across Canada. 2). The costs associated with potentially unnecessary arthroscopy. 3). The characteristics of surgeons performing knee arthroscopy in older adults. Data were derived from National Ambulatory Care Reporting System (NACRS), the Discharge Abstract Database (DAD) and the National Physician Database for years 2011-12 to 2019-20. The study included all elective knee arthroscopies (CCI codes 1.VG.80.DA,1.VG.80.FY and 1.VG.87.DA) performed in day surgery and acute care settings in 9 provinces and 3 territories of Canada. Quebec was not included in the analysis due to different reporting methods. We set a threshold of 60 years of age at which it would be highly unlikely that a patient would undergo arthroscopy to treat anything other than osteoarthritis or degenerative meniscal tear. Trends at national and provincial levels were analyzed using regression. Costs were estimated separately using the 2020 case mix groups (CMG) and comprehensive ambulatory care classification system (CACS) methodologies. Surgeons were classified by decade of graduation from medical school (1989 and prior, 1990-99, 2000-09 and 2010+) and categorized based on the proportion of their patient population who were above (“high proportion inappropriate”) or below (“low proportion inappropriate”) the overall national proportion of ≥ 60 years of age. The number of knee arthroscopies decreased by 37% (42,785 in 2011-12 to 27,034 in 2019-20) overall and 39% (11,103 in 2011-12 to 6,772 in 2019-20) in those 60 years and older (p 25% of patients 60 years and older. Fifty four percent of surgeons who graduated prior to 1989 were considered high proportion inappropriate, whereas only 30.1% of surgeons who graduated in 2010 or later were considered high proportion inappropriate (p < 0 .0001). Knee arthroscopy continues to be a common procedure in patients over 60 despite strong evidence for lack of benefit. Lower rates in this population in some provinces are encouraging for potential opportunity for improvement. Efforts at practice change should be targeted at surgeons in practice the longest. Canada spends over $12,000,000 per year on this procedure, decreasing its use could allow these resources to be directed to other areas of orthopaedics that provide higher value care

Introduction. 47 yrs male patient had a prior history. 2005 Fx. proximal tibia (open Fx.). 2007 Metal removal. 2008 Arthroscopic debridement (2 times). He visited out hospital with severe pain and tenderness X-ray (Fig 1) and MRI (Fig 2) findings as follows. Conclusively, He had a chorinic osteomylitis of proximal tibia with soft tissue absess. 1st Surgery. I did arthroscopic debridement Arthroscopic finding shows synovitis, meniscus tear and chondromalacia. I did meticulous debridement (irrigation & curettage). 2nd Surgery. He did primary total knee arthro-plasty instead of two-stage exchange arthroplasty in may, 2010 at the another hospital. 3rd Surgery. After 7 months since he had did total knee arthroplasty, he visited to my hospital again with sudden onset of painful swelling & heating sensation. 4th Surgery. I did second stage reimplantation for infected total Knee arthroplasty after 7 weeks. Now he got a pain relief & ROM restroration. Results. Follow up 12 months X-ray showing all implants to be well-positioned and stable. Clinically, there was no implant considered to be loose. In this study, the knee society and functional scores at final follow up were 82 and 68. Conclusion. The infection after sequales of open proximal tibia fracture is treated by two-stage exchange total knee arthroplasty instead of primary total knee arthroplasty. Two-stage reimplantation of an infected total knee arthroplasty using a static antibiotic-cement spacer achieved an infection control and improvement in the clinical result 3). We use an antibiotic-loaded cement spacer(ALACS) preserved knee function between stages, resulting in effective treatment of infection, facilitation of reimplantation, and improved patient satisfaction 1). The principle surgical technique used for two-stage revision of infected total knee including: (1) exposure, (2) implant removal and debridement, and (3) construction of both static and mobile antibiotic spacers 2

Aim. Treatment success of debridement, antibiotics and implant retention (DAIR) is in early periprosthetic joint infection (PJI) is largely dependent on the presence or absence of a mature biofilm. In what time interval a mature biofilm develops is still unclear, and therefore, the time point at which DAIR should be disrecommended remains to be established. This large multicenter trial evaluated the failure rates of DAIR for different time intervals from index arthroplasty to DAIR in early PJI. Method. We retrospectively evaluated patients with early PJI treated with DAIR between 1996 and 2016. Early PJI was defined as a PJI that developed within 90 days after index arthroplasty. Patients with hematogenous infections, arthroscopic debridements and a follow-up less than one year were excluded. Treatment failure was defined as 1) any further surgical procedure related to infection 2) PJI-related death, or 3) long-term suppressive antibiotics, all within one year after DAIR. Results. A total of 769 patients were analyzed. Treatment failure occurred in 294 patients (38.2%), and was highest in the early (0–2 weeks) and late (6–12 weeks) post-surgical course: 0–2 weeks: 42.0% (95/226); 2–4 weeks: 37.8% (143/378); 4–6 weeks: 29.0% (29/100), and 6–12 weeks: 41.5% (27/65). Exchange of modular components was performed to a lesser extent in the early compared to the late post-surgical course (40.7% vs 63.2%, p<0.001). The percentage of positive cultures obtained during DAIR decreased according to the time interval from index arthroplasty to DAIR: 0–2 weeks: 88.6%; 2–4 weeks: 86.5%; 4–6 weeks: 75.1%; and 6–12 weeks: 63.2%, p<0.001. The causative microorganisms and the duration of symptoms were comparable between groups (6.7 days, SD ± 5.9, p=0.135). Conclusions. Although failure rates increase when a DAIR is performed more than six weeks after index arthroplasty, DAIR is still a viable treatment option in these patients in case DAIR is performed as soon as symptoms of infections arise and modular components can be exchanged

Before reverse shoulder replacement was an option for rotator cuff tear arthropathy the treatment modalities were limited to injections and physical therapy for pain control, arthroscopic debridement with or without biceps tenodesis/tenotomy and hemiarthroplasty. Functional improvement was limited with these treatment options and success for pain control was moderate at best. The destructive nature of the rotator cuff deficient shoulder continued with medialization of the glenoid and erosion of the acromion seen even after replacement with hemiarthroplasty. The end result usually left the patient with a pseudo paralysis of the shoulder region functionally and uncontrolled pain that made later revision with a reverse implant difficult or impossible. Reverse arthroplasty was released for use in United States in 2004 for rotator cuff tear arthropathy. This initial procedure had a number of related complications that have been improved on over time with changes in implant design and better operative techniques. The long term results with reverse total shoulder arthroplasty have made this the procedure of choice for contained cuff tear arthropathy

Despite the successful, durable results, concern remains for using TKA in patients with isolated patello-femoral OA, as it requires an extensive surgical exposure and bone resection, a long recovery time, and a potentially more complex revision than that required for a patient with a failed patello-femoral arthroplasty (PFA). PFA was introduced in the late 1970s. While PFA was successful in providing pain relief, the procedure did not gain widespread use because of initial design limitations that predisposed to PF maltracking, catching, and subluxation. The mechanical complications associated with first-generation PFA offset the potential advantages of maintaining the knee's native soft tissues and spurred efforts to improve implant design, and to refine surgical techniques and patient selection. Over the past two decades, second generation PFAs incorporated changes in implant design and instrumentation and have shown promising results when used in the properly selected patient population. In addition, with improved instrumentation and robotics, adequate implant alignment and rotation can be achieved in the majority of patients, including those with severe patellofemoral dysplasia. Our meta-analysis of TKA and PFA for the treatment of isolated patello-femoral OA showed that the rate of complications of patients undergoing PFA was 30% after a median follow up of 5.3 years, which is significantly higher than the 7% rate of complications in patients who underwent TKA. The most frequent type of complication associated with PFA was mechanical (including loosening and instability), which is consistent with the malalignment and maltracking-related failures previously reported. The incidence of re-operation after PFA (21%) was significantly higher than that seen after TKA (2%). The most frequent indication for re-operation after PFA was mechanical failure (7%), followed by progression of OA (6%), and persistent pain or stiffness (5%). The most common re-operations after PFA were conversion to TKA, revision of PFA components, lateral releases, open or arthroscopic debridement, manipulations under anesthesia, and bony and/or soft tissue extensor mechanism re-alignment procedures. In our study, 11% of patients treated with PFA underwent a revision arthroplasty, with 4% undergoing revision PFA and 7% undergoing conversion to TKA. Our comparison of patients who were treated with second-generation PFA designs versus TKA showed no difference in the rate of complications, re-operation, or revision arthroplasty. Additionally, length of follow-up did not significantly influence any of these outcomes when comparing second-generation PFA and TKA. These observations provide support for the use of current PFA designs. The mechanical complications and subsequent re-operations that affected first-generation PFA designs appear to be of less concern with proper patient selection, meticulous surgical technique, current implant designs and peri-operative care. While it is difficult to predict the survivorship of current PFA designs, it is our expectation that patient selection will continue to be a critical component in determining long-term results. The potential benefit of providing pain relief while preserving the tibiofemoral articulations makes PFA a promising treatment option

Historical perspective: Irrigation and debridement (I&D) with modular exchange has historically been the recommended treatment for acute post-operative periprosthetic joint infection (PJI), and acute hematogenous PJI. The theory supporting this practice was that because the bacterial glycocalyx had not yet formed by these early time points, by simply debriding the intra-articular bacterial load and exchanging the modular parts, one could potentially eradicate the infection, retain the prior components, and minimise morbidity to the patient. More recently, literature is coming out suggesting that this may not necessarily be the case. The vast majority of published research on the outcomes following I&D for treatment of PJI has focused on either cohorts of total knee arthroplasty patients or combined cohorts of total hip and knee patients. For this reason, it is difficult to tease out the differential success rate of periprosthetic hip vs. knee infections. Sherrell et al. performed a systematic review of the existing literature and created a table detailing the failure rates for various published articles on I&D for periprosthetic TKA infection. Since it is the glycocalyx that has been thought to be the reason for treatment failure of many cases of PJI treated with I&D, many authors have implicated staphylococcal species as a predictor of a negative outcome with failure rates ranging from 30–35%. Methicillin resistant organisms have been shown to be particularly difficult to eradicate with an isolated I&D, with a 72–84% failure rate at 2 year follow-up. Interestingly, a recent study by Odum et al. suggests that neither the infecting microbe, nor the antibiotic resistance profile of the organism, as has been classically thought, actually predicts success of I&D. Previous reports have indicated that the ability of I&D to control infection is related to the duration of symptoms and its timing relative to the index surgery. However, more recent literature is coming out to support the contrary. Koyonos et al. reviewed the outcomes of a series of 138 cases of PJI treated with I&D based on acuity of infection and concluded that an I&D has a limited role in controlling PJI regardless of acuity. Intuitively, the physical health of the host/patient should influence the success of I&D for treatment of PJI. Several authors have shown that an immunocompromised state is a predictor of treatment failure. Furthermore, Azzam et al. reported that patients with a higher American Society of Anesthesia (ASA) score, a proxy of severity of medical comorbidities, had a significantly higher failure rate. Although potentially appealing due to relative ease of execution and minimal surgical morbidity, the ability to successfully eradicate infection with an arthroscopic procedure may be compromised. Given the inability to perform a radical surgical debridement, nor exchange modular components, arthroscopic debridement should be used with extreme reservation in any case of PJI, regardless of the host, nature of the infecting organism, or acuity of infection. I&D as a conservative, less morbid alternative to two-stage exchange - There is a growing body of literature to suggest that an I&D with modular component exchange may not be the benign, less morbid alternative to the ‘gold standard’ two-stage exchange arthroplasty. In fact, Fehring et al. has reported that the success of a two-stage antibiotic spacer exchange arthroplasty may be compromised by an initial I&D. They found that patients who were initially treated with an I&D only had a 66% chance of eradicating infection following a two-stage exchange arthroplasty, in contrast to historical reports of 80–90% success

A retrospective review of 57 military patients undergoing ankle arthroscopy between 1999 and 2011 was performed. A case-note review of medical records was undertaken pertaining to military role, ankle injury sustained, mechanism, presenting symptoms and their duration. Arthroscopic findings were compared to findings on radiographs and MRI scans. At first presentation 23 patients had features of arthritis on radiographs. We found MRI was both highly sensitive (97.7%) and specific (93.4%) in detecting osteochondral defects (OCD). 16 of the patients had evidence of osteochondral injury. All OCDs picked up on MRI were confirmed at arthroscopy. Ankle injury may not be a benign injury in military personnel, with over half of these young patients having radiological features of osteoarthritis at presentation. We found MRI an effective tool for identifying occult injuries not seen on radiographs. Lateral ligament injury with associated gutter scarring can be successfully treated with arthroscopic debridement. This suggests pseudoinstability rather than a true mechanical instability as the main cause for patient's symptoms in this cohort

Knee stiffness is a well-recognised postoperative problem that has been reported to occur in 6% to 15% of all patients who undergo total knee arthroplasty (TKA), and there are multiple preoperative, intraoperative, and postoperative risk factors that may predispose patients to postTKA knee stiffness. Preoperative risk factors include poor baseline range of motion (ROM), obesity, and a history of previous knee surgery and/or trauma. Potential intraoperative risk factors for having a stiff knee are malalignment, gap imbalance, and under-resection of patella. Possible postoperative risk factors include heterotopic ossification, pain, poor patient motivation, and poor physical therapy compliance. Three commonly used adjuvant treatments for this condition are custom knee devices, Botox, and ASTYM. These treatment modalities are most effective when used within 6 weeks after surgery. Multiple case series have reported that CKD can improve range of motion while maximising patient-reported functional outcomes. Botox can improve range of motion by paralyzing the muscle where the contracture is located. ASTYM therapy has recently been reported to resolve muscle contractures by effectively stimulating tissue turnover, scar tissue resorption, and regeneration of the normal soft tissue structure. When these adjuvant therapies fail, manipulation under anesthesia has been reported to be efficacious in restoring some of the original ROM. If this fails, there are surgical treatment options such as arthroscopic debridement, surgical release, revision TKA, or peroneal nerve release

Arthroscopic intervention for early symptoms of arthrosis of the knee was a well-established procedure until Moseley cited his study showing no difference in outcomes when compared to “sham” surgery. Now there is no opportunity for reimbursement with arthroscopic debridement unless mechanical internal derangement can be documented. There are, however, several specific lesions of arthrosis which respond well to arthroscopic intervention and are reimbursed by third party payers. Arthroscopic three compartment microfracture with non-weight bearing and passive motion for eight weeks post- op has significantly relieved symptoms. Second look biopsies have confirmed type II hyaline cartilage and increased joint interval. Proper patient selection is paramount and guidelines will be discussed. Isolated severe patellofemoral arthrosis with patella subluxation responds to arthroscopic patella lateral facetectomy. Jones has reported significant pain relief up to two years with this excellent option for a difficult patient problem. The technique and results will be presented in detail. Loss of terminal extension in the arthritic knee can accelerate deterioration and force earlier decision for TKA. Parson's third tubercle is an osteophyte that forms just anterior to the ACL insertion on the tibia and is the frequent cause of extension loss. Arthroscopic resection of the tubercle results in increased extension and diminishes the stress concentration assuring better longevity for the native knee. The diagnostic characteristics, resection techniques and results of the Dallas series will be presented