Ankle arthrodesis is the gold standard for treatment of end stage ankle arthritis. We analysed the data of 124 Ankle Arthrodesis (Open Ankle Arthrodesis (OAA) −27; Arthroscopic Ankle Arthrodesis (AAA)- 97) performed between January 2005 and December 2015 by fellowship trained foot and ankle surgeons in a single institution. Based on preoperative deformity (AAA- 28 degree valgus to 26 degrees varus; OAA- 41 degree valgus to 28 degree varus), they were subdivided into 2 groups based upon deformity more than 15 degrees. Union rates, time to union, length of hospital stay and patient related factors like smoking, alcoholism, diabetes, BMI were assessed.

Mean age of patients was 60 years (Range 20 to 82 years)(Male:Female-87:32). Overall fusion rate was 93% in AAA and 89% in OAA (p=0.4). On sub group analysis of influence of preoperative deformity, there was no difference in union rates of AAA versus OAA. 7 patients in AAA and 3 in OAA required further procedures. Average time to union was 13.7 in AAA and 12.5 weeks in OAA (p=0.3). Average hospital stay was 2.6 days in AAA and 3.8 days in OAA (p=0.003). Smoking, alcoholism, Diabetes, BMI did not have any correlation with union rates. Although both AAA and OAA showed good union rates, hospital stay was significantly shorter in AAA. A larger deformity did not adversely affect union rates in AAA. Time to union was higher in AAA though it was statistically insignificant. Lifestyle risk factors did not have cumulative effect on union.

We conclude that AAA is a reproducible method of treating end stage tibiotalar arthritis irrespective of preoperative deformity and patient related factors.

Abstract

Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization. The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week. One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups. Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone

Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization. The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week. One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups. Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone

Recurrent anterior shoulder instability (RASI) is related to progressive bone loss on the glenoid and on the humeral head. Bone deficit magnitude is a well-recognized predictor of recurrence of instability after an arthroscopic Bankart surgery, but the best way to measure it is unknown. In this study, we want to determine which measurement method is the best predictor of recurrence of instability and function. For 10 years now, all patients undergoing surgery for RASI in 4 centers are included in a prospective study: the LUXE cohort. Patients with a pre-operative CT-scan and a minimum of 1-year follow-up were included. ISIS score was used to stratify patients. WOSI and Quick-Dash questionnaires were used to characterise function. Bone defects were assessed using the Clock method, the Glenoid Ratio, the Humeral Ratio, the Glenoid Track method and the angle of engagement in the axial plane. A total of 262 patients are now included in the LUXE study. One hundred and three patients met the inclusion criteria for analysis with a majority of male (79%) and a mean age is 28 years old. The median number of dislocations prior to surgery was 6. Seventy patients had an arthroscopic Bankart repair and 33 patients underwent an open Latarjet procedure. The ISIS score for these groups were of 2.7 and 4.8 respectively (p<0.001). The mean bone defect on the glenoid was of 1h51 with the Clock method (range: 0h-4h48; SD=1h46) and of 9% for the glenoid ratio (0–37%, 10%). On the humeral side, the bone defect was of 1h59 (0h-4h08; 0h49) for the Humeral clock method, 15% (0–36%; 6%) with the ratio method and 71 degrees of external rotation (SD=30 degrees) with the angle of engagement measurement. On the combined evaluations, 53 patients presented an off-track lesion, with mean combined hours of 3h53 (SD= 2h13). The greatest correlation obtained was between the glenoid ratio and the glenoid clock method (r=0.919, p<0.001). Eighteen patients had a recurrence of shoulder dislocation after the initial surgery, leading to a recurrence rate of 23% in arthroscopic surgery versus six percent after a Latarjet (OR= 4.6, p=0.034). No bone defect was correlated to Latarjet failure. For the arthroscopic group, the risk of recurrence was related to a smaller angle of engagement of the Hill-Sachs (p=0.05), a smaller Humeral clock measurement (p=0.034) and a longer follow-up (p=0.006). No glenoid or combined measurements were correlated with arthroscopic procedure failure. Recurrence of dislocation was associated to worst function according to the WOSI (1036 vs 573, p=0.002) and DASH (32 vs 15, p=0.03). Even with lower ISIS score, arthroscopic procedures are still leading to high risk of recurrence in this “all comer” consecutive cohort study AND it is related to humeral side parameters. Recurrence is also affecting daily function and creating higher anxiety related to the shoulder

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

Malnutrition is an important consideration during the perioperative period and albumin is the most common laboratory surrogate for nutritional status. The purpose of this study is to identify if preoperative serum albumin measurements are predictive of infection following arthroscopic procedures. Patients undergoing knee, shoulder or hip arthroscopy between 2006–2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with an arthroscopic current procedural terminology code and a preoperative serum albumin measurement were included. Patients with a history of prior infection, including a non-clean wound class, pre-existing wound infection or systemic sepsis were excluded. Independent t-tests where used to compare albumin values in patients with and without the occurrence of a postoperative infection. Pre-operative albumin levels were subsequently evaluated as predictors of infection with logistic regression models. There were 31,906 patients who met the inclusion criteria. The average age was 55.7 years (standard deviation (SD) 14.62) and average BMI was 31.7 (SD 7.21). The most prevalent comorbidities were hypertension (49.2%), diabetes (18.4%) and smoking history (16.9%). The average preoperative albumin was 4.18 (SD 0.42). There were 45 cases of superficial infection (0.14%), 10 cases of wound dehiscence (0.03%), 17 cases of deep infection (0.05%), 27 cases of septic arthritis or other organ space infection (0.08%) and 95 cases of any infection (0.30%). The preoperative albumin levels for patients who developed septic arthritis (mean difference (MD) 0.20, 95% CI, 0.038, 0.35, P = 0.015) or any infection (MD 0.14, 95% CI 0.05, 0.22, P = 0.002) were significantly lower than the normal population. Additionally, disseminated cancer, Hispanic race, inpatient status and smoking history were significant independent risk factors for infection, while female sex and increasing albumin were protective towards developing any infection. Rates of all infections were found to increase exponentially with decreasing albumin. The relative risk of infection with an albumin of 2 was 3.46 (95% CI, 2.74–4.38) when compared to a normal albumin of 4. For each albumin increase of 0.69, the odds of developing any infection decreases by a factor of 0.52. This study suggests that preoperative serum albumin is an independent predictor of septic arthritis and all infection following elective arthroscopic procedures. Although the effect of albumin on infection is modest, malnutrition may represent a modifiable risk factor with regard to preventing infection following arthroscopy

Concepts in glenoid tracking and treatment strategies of glenoid bone loss are well established. Initial observations in our practice in Singapore showed few patients with major bone loss requiring glenoid reconstructions. This led us to investigate the incidence of and the extent of bone loss in our patients with shoulder instability. Our study revealed bony Bankart lesions were seen in 46% of our patients but glenoid bone loss measured only 6–10% of the glenoid surface. In the same study we found that arthroscopic labral repair with capsular plication and Mason-Ellen suturing (Hybrid technique) was sufficient to stabilise patients with bipolar bone defects and minor glenoid bone loss. This led us to develop the concept of minor bone loss and a new algorithm. Our algorithm and strategies to deal with major bone loss will also be discussed, and techniques & outcomes of Arthroscopic Bony Bankart repair, Arthroscopic Glenoid Reconstruction and Arthroscopic Remplissage procedures will be shown

Arthroscopic hip procedures have increased dramatically over the last decade as equipment and techniques have improved. Patients who require hip arthroscopy for femoroacetabular impingement on occasion require surgery on the contralateral hip. Previous studies have found that younger age of presentation and lower Charlson comorbidity index have higher risk for requiring surgery on the contralateral hip but have not found correlation to anatomic variables. The purpose of this study is to evaluate the factors that predispose a patient to requiring subsequent hip arthroscopy on the contralateral hip. This is an IRB-approved, single surgeon retrospective cohort study from an academic, tertiary referral centre. A chart review was conducted on 310 primary hip arthroscopy procedures from 2009-2020. We identified 62 cases that went on to have a hip arthroscopy on the contralateral side. The bilateral hip arthroscopy cohort was compared to unilateral cohort for sex, age, BMI, pre-op alpha angle and centre edge angle measured on AP pelvis XRay, femoral torsion, traction time, skin to skin time, Tonnis grade, intra-op labral or chondral defect. A p-value <0.05 was deemed significant. Of the 62 patients that required contralateral hip arthroscopy, the average age was 32.7 compared with 37.8 in the unilateral cohort (p = 0.01) and BMI was lower in the bilateral cohort (26.2) compared to the unilateral cohort (27.6) (p=0.04). The average alpha angle was 76.3. 0. in the bilateral compared to 66. 0. in the unilateral cohort (p = 0.01). Skin to skin time was longer in cases in which a contralateral surgery was performed (106.3 mins vs 86.4 mins) (p=0.01). Interestingly, 50 male patients required contralateral hip arthroscopy compared to 12 female patients (p=0.01). No other variables were statistically significant. In conclusion, this study does re-enforce existing literature by stating that younger patients are more likely to require contralateral hip arthroscopy. This may be due to the fact that these patients require increased range of motion from the hip joint to perform activities such as sports where as older patients may not need the same amount of range of motion to perform their activities. Significantly higher alpha angles were noted in patients requiring contralateral hip arthroscopy, which has not been shown in previous literature. This helps to explain that larger CAM deformities will likely require contralateral hip arthroscopy because these patients likely impinge more during simple activities of daily living. Contralateral hip arthroscopy is also more common in male patients who typically have a larger CAM deformity. In summary, this study will help to risk stratify patients who will likely require contralateral hip arthroscopy and should be a discussion point during pre-operative counseling. That offering early subsequent or simultaneous hip arthroscopy in young male patients with large CAMs should be offered when symptoms are mild

Magnetic resonance imaging (MRI) scans are widely used in the assessment of knees, often prior to arthroscopic procedures. The reporting of chondral damage on MRI scans can be variable. The correlation between MRI reports of chondral damage and that found at arthroscopy is often inconsistent. The aim of this study was to identify how well MRI reports correlated with the extent of chondral damage found at arthroscopy. A retrospective case-note review of a single-surgeon series of 175 arthroscopic procedures was performed. 83 patients were included in the study. The remainder were excluded if an MRI scan had not been performed, or had been performed more than 3 months prior to surgery. The condition of the articular cartilage demonstrated by MRI was compared to that found at arthroscopy. Data was analysed for presence and extent of chondral damage. Comparison between MRI and arthroscopy findings showed high Specificity (90%) and Negative Predictive Values (89%) for chondral damage, but low Sensitivity (46%). Cohen's kappa values < 0.2 revealed very poor correlation for the extent of damage. This study demonstrates that MRI is good at describing whether articular damage is present but does not reliably describe the extent of the damage

Arthrosis of the hip joint can be a significant source of pain and dysfunction. While hip replacement surgery has emerged as the gold standard for the treatment of end stage coxarthrosis, there are several non-arthroplasty management options that can help patients with mild and moderate hip arthritis. Therefore, the purpose of this paper is to review early prophylactic interventions that may help defer or avoid hip arthroplasty. Nonoperative management for the symptomatic hip involves minimizing joint inflammation and maximizing joint mobility through intra-articular joint injections and exercise therapy. While weight loss, activity modifications, and low impact exercises is generally recommended for patients with arthritis, the effects of these modalities on joint strength and mobility are highly variable. Intra-articular steroid injections tended to offer reliable short-term pain relief (3–4 weeks) but provided unreliable long-term efficacy. Additionally, injections of hyaluronic acid do not appear to provide improved pain relief compared to other modalities. Finally, platelet rich plasma injections do not perform better than HA injections for patients with moderate hip joint arthrosis. Primary hip joint arthrosis is rare, and therefore treatment such as peri-acetabular osteotomies, surgical dislocations, and hip arthroscopy and related procedures are aimed to minimise symptoms but potentially aim to alter the natural history of hip diseases. The state of the articular cartilage at the time of surgery is critical to the success or failure of any joint preservation procedures. Lech et al. reported in a series of dysplastic patients undergoing periacetabular osteotomies that one third of hips survived 30 years without progression of arthritis or conversion to THA. Similarly, surgical dislocation of the hip, while effective for treatment of femoroacetabular impingement, carries a high re-operation rate at 7 years follow up. Finally, as the prevalence of hip arthroscopic procedures continues to rise, it is important to recognise that failure to address the underlying structural pathologies can lead to failure and rapid joint destruction. In summary, several treatment modalities are available for the management of hip pain and dysfunction in patients with a preserved joint space. While joint preservation procedures can help improve pain and function, they rarely alter the natural history of hip disease. The status of the articular cartilage at the time of surgery is the most important predictor of treatment success or failure

Introduction. The aim of the study was to compare and contrast the clinical outcome of conversion of practice of a shoulder surgeon from open to arthroscopic shoulder stabilisation for traumatic anterior shoulder instability. Patients and Methods. Comparison of a cohort consecutive series of 24 patients treated by open stabilisation and a prospective consecutive cohort series of 30 patients treated by arthroscopic stabilisation. Clinical outcomes were assessed with Oxford Shoulder Score Instability (OSS-I) and a Patient Satisfaction Survey at a minimum of 1 year follow up. The operation time as well as cost analysis were also evaluated. Results. The average OSS-I for open stabilisation was 39.6 (range 19-48) as compared to 39.8 (range 23-48) with the arthroscopic group and these scores did not show a statistically significant difference. Both cohorts were pleased with the clinical outcome and were happy to recommend the procedure to others. No complications in either group were seen. Operative time and costs were significantly more in the open group, even taking into account initial learning curve of the arthroscopic method. All arthroscopic procedures were performed as day-cases compared to over-night stays for the open group also providing better use of hospital resources and cost savings. Conclusion. After appropriate surgical training, the conversion from open to arthroscopic stabilisation can be performed without affecting clinical outcome or patient satisfaction. This study provides surgeons with confidence to change methods to gain the advantages of the arthroscopic procedure, which included reduced theatre time, day case surgery and earlier return to work and sport

Shoulder arthritis in the young adult is a deceptive title. The literature is filled with articles that separate outcomes based on an arbitrary age threshold and attempt to provide recommendations for management and even potential criteria for implanting one strategy over another using age as the primary determinant. However, under the age of 50, as few as one out of five patients will have arthritis that can be accurately classified as osteoarthritis. Other conditions such as post-traumatic arthritis, post-surgical arthritis including capsulorrhaphy arthropathy, and rheumatoid arthritis create a mosaic of pathologic bone and soft tissue changes in our younger patients that distort the conclusions regarding “shoulder arthritis” in the young adult. In addition, we are now seeing more patients with unique conditions that are still poorly understood, including arthritis of the pharmacologically performance-enhanced shoulder. Early arthritis in the young adult is often recognised at the time of arthroscopic surgery performed for other preoperative indications. Palliative treatment is the first option, which equals “debridement.” If the procedure fails to resolve the symptoms, and the symptoms can be localised to an intra-articular source, then additional treatment options may include a variety of cartilage restoration procedures that have been developed primarily for the knee and then subsequently used in the shoulder, including microfracture, and osteochondral grafting. The results of these treatments have been rarely reported with only case series and expert opinion to support their use. When arthritis is moderate or severe in young adults, non-arthroplasty interventions have included arthroscopic capsular release, debridement, acromioplasty, distal clavicle resection, microfracture, osteophyte debridement, axillary nerve neurolysis, and bicep tenotomy or tenodesis, or some combination of these techniques. Again, the literature is very limited, with most case series less than 5 years of follow-up. The results are typically acceptable for pain relief, some functional improvement, but not restoration to completely normal function from the patient's perspective. Attempts to resurface the arthritic joint have resulted in limited benefits over a short period of time in most studies. While a few remarkable procedures have provided reasonable outcomes, they are typically in the hands of the developer of the procedure and subsequently, other surgeons fail to achieve the same results. This has been the case with fascia lata grafting of the glenoid, dermal allografts, meniscal allografts, and even biologic resurfacing with large osteochondral grafts for osteoarthritis. Most surgical interventions that show high value in terms of improvement in quality of life require 10-year follow-up. It is unlikely that any of these arthroscopic procedures or resurfacing procedures will provide outcomes that would be valuable in terms of population healthcare; they are currently used on an individual basis to try to delay progression to arthroplasty, with surgeon bias based on personal experience, training, or expert opinion. Arthroplasty in the young adult remains controversial. Without question, study after study supports total shoulder arthroplasty over hemiarthroplasty once the decision has been made that joint replacement is the only remaining option

The spread of viral diseases such as HIV has highlighted the importance of protecting medical personnel against contamination from blood. We have assessed the frequency of the perforation of surgical gloves during orthopaedic and trauma surgery and compared the efficiency of single and double gloving. We examined all the gloves used by surgeons for a period of two months. There were 1769 gloves from 349 operations. Perforations occurred in 18.5% of conventional and 5.8% of arthroscopic procedures. The risk of contamination from blood was 13 times higher when using single compared with double gloves. Surprisingly, the combination of two regular gloves was much less efficient than double indicator gloves when comparing the rate of perforation of the inner glove when the outer had been damaged (24% vs 4.9%; p = 0.02). We recommend double gloving in orthopaedic surgery in general and also in long arthroscopic procedures

Ulnocarpal impaction (UCI) is a common cause of ulnar-sided wrist pain. UCI typically occurs in wrists with positive ulnar variance, which causes altered loading mechanics between the ulnar head, lunate and triquetrum. However, many individuals with positive ulnar variance never develop UCI, and some with neutral or negative ulnar variance do experience UCI. This suggests that other variables contribute to the development of UCI. Suspected culprits include lunate morphology, and dynamic changes with loaded (grip) pronation. If these anatomic variations are contributing to UCI, we expect them to influence functional impairment scores. Therefore, the objective of this study was to evaluate the relationship between radiographic parameters and pre-surgical upper extremity patient-rated outcomes scores (PROS) in patients with a diagnosis of UCI. Retrospective cohort study of patients undergoing ulnar shortening osteotomy or arthroscopic wafer procedure for UCI. Data derived from prospectively collected departmental database that captured demographic, clinical, functional and radiographic information. Radiographic parameters evaluated were: lunate morphology [presence vs. absence of hamate facet; Antuna-Zapico (A-Z) classification], and dynamic changes on grip view [difference in lunate-ulnar head distance (LUD); difference in lunate uncovering index (LUI)]. PROS assessed were QuickDASH and Patient-Rated Wrist Evaluation (PRWE) scores, collected at patient enrolment. ANOVA was used to assess for differences in PROS between A-Z classification groups. Student's t-test was used to assess for differences in PROS based on presence/absence of a hamate facet. Regression analysis evaluated a relationship between change in LUD with grip and PROS, and change in LUI with grip and PROS. Preliminary analysis included 23 wrists, with a mean patient age of 48.9 years [standard deviation (SD) 14.5 years]. Forty-eight percent were male, and the dominant limb was involved in 52.2% of cases. Average QuickDASH and PRWE scores at enrolment were 50.9 (SD 22.2) and 62.2 (SD 22.0), respectively. Assessment of radiographs revealed 17 patients (73.9%) without a hamate facet. Five patients (21.7%) had A-Z Type I lunate morphology, and nine (39.1%) had Type II and Type III morphology, respectively. ANOVA revealed no differences in enrolment QuickDASH (p = 0.185) or PRWE (p = 0.256) scores between A-Z classification groups. Similarly, Student's t-test found no difference based on presence/absence of a hamate facet (QuickDASH p = 0.594; PRWE p = 0.573). Regression analysis revealed no relationship between change in LUD with grip and PROS (QuickDash R2 = 0.020, p = 0.619; PRWE R2 = 0.009, p = 0.733), and no relationship between change in LUI with grip and PROS (QuickDash R2 = 0.000, p = 0.913; PRWE R2 = 0.010, p = 0.722). Preliminary results suggest no relationship between A-Z classification lunate morphology, presence/absence of a hamate facet, change in LUD, or change in LUI and pre-surgical PROS. It is unclear if our findings represent the true relationship between these radiographic parameters and PROS, or reflect our preliminary sample size. Data analysis is ongoing to add clarity to this question

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

Recent literature has demonstrated that conventional arthroscopic techniques do not adequately visualise areas of predilection of pathology of the long head of biceps (LHB) tendon and are associated with a 30–50% rate of missed diagnoses. The aim of this study was to evaluate the safety, effectiveness and ease of performing biceps tenoscopy as a novel strategy for reducing the rate of missed diagnoses. Five forequarter amputation cadaver specimens were studied. The pressure in the anterior compartment was measured before and after surgical evaluation. Diagnostic glenohumeral arthroscopy was performed and the biceps tendon was tagged to mark the maximum length visualised by pulling the tendon into the joint. Biceps tenoscopy was performed using 3 different techniques (1. Flexible video-endoscopy, 2. Standard arthroscopy via Neviaser portal. 3. Standard arthroscope via antero-superior portal with retrograde instrumentation). Each was assessed for safety, ease of the procedure and whether the full length of the extra-articular part of the LHB tendon could be visualised. The t-test was used to compare the length of the LHB tendon visualised at standard glenohumeral arthroscopy vs that visualised at biceps tenoscopy. An open dissection was performed after the arthroscopic procedures to evaluate for an iatrogenic injury to local structures. Biceps tenoscopy allowed visualisation to the musculotendinous junction in all cases. The mean length of the tendon visualised was therefore significantly greater at biceps tenoscopy (104 mm) than at standard glenohumeral arthroscopy (33 mm) (mean difference 71 mm, p<0.0001). Biceps tenoscopy was safe with regards to compartment syndrome and there was no difference between pre- and post-operative pressure measurements (mean difference 0 mmHg, p=1). No iatrogenic injuries were identified at open dissection. Biceps tenoscopy allows excellent visualisation of the entire length of the LHB tendon and therefore has the potential to reduce the rate of missed diagnoses. This study did not demonstrate any risk of iatrogenic injury to important local structures or any risk of compartment syndrome. Clinical evaluation is required to further validate this technique

Introduction. We describe a single stage arthroscopic procedure for the treatment of articular cartilage defects in the knee. The novel procedure involves microdrilling and application of atellocollagen and fibrin gel. The aim of the study was to evaluate the clinical outcomes at 4 years. Materials and Methods. A prospective study of 30 patients with symptomatic ICRS grade III/IV chondral defects which were assessed clinically and radiologically. The lesions were located on the MFC, LFC, trochlea or patella, ranging from 2–8cm2. The surgical procedure involved debridement of the lesion, microdrilling and application of atellocollagen and fibrin gel under CO2 insufflation. Patients were clinically assessed using the Lysholm, IKDC and KOOS scores. Radiological assessment used the MOCART score. Results. At 4 year follow-up:. Lysholm score was 80.46 ± 24.7, up from 51.7 ± 27.1 pre-operatively (p < 0.05). KOOS (symptomatic) was 89, up from 66.2 pre-operatively. IKDC (subjective) was 78.6, up from 41 preoperatively. MOCART score for all lesions was 71.3. The mean T2* relaxation-times for the repair tissue and native cartilage were 28.8 and 29.7 respectively. dGEMRIC scan suggests hyaline like repair tissue. Conclusion. Our technique shows encouraging results at 4 year follow-up as assessed by reliable validated scores and qualitative MRI scans

The incidence of frozen shoulder (FS) as a complication of simple arthroscopic shoulder surgery has yet to be defined. A single-surgeon case series of patients undergoing arthroscopic subacromial decompression (ASD) or ASD with arthroscopic acromioclavicular joint (ACJ) excision was analysed to establish FS rate, this cohort was then compared to a matched group of primary FS patients. Retrospective analysis of 200 consecutive cases was undertaken. All procedures listed, performed and reviewed by the senior author. 96 underwent ASD and 104 underwent ASD and ACJ excision. 6-months follow-up minimum. Incidence of frozen shoulder was 5.21% (ASD) and 5.71% (ASD+ACJ excision). Mean age was 52.3 years (95% CI: 47.4 to 57.2) of the patients that developed FS, compared to 57.2 years (95% CI: 55.2 to 59.2) in the patients who did not and 52 years (95% CI: 50.7 to 53.3) in the primary FS cohort (n=136). 9.1% of post-operative FS were diabetic compared to 17.1% of primary FS. 63.6% were female in the post-operative FS group, 47.1% in the primary FS group. Our results suggest that the risk of FS following simple arthroscopic procedures is 5%, with no increased risk if the ACJ is also excised. This cohort has the same average age as a primary FS. There is a trend toward female sex and diabetes does not increase the risk

Non-tuberculous mycobacteria (NTM)—previously considered as saprophytic organisms—are now increasingly recognized as human pathogens [1, 2]. Although humans are routinely exposed to NTM, clinical infection rates are low; further, these infections typically occur in immunocompromised patients. However, an increasing incidence of NTM infections in immunocompetent hosts—caused by direct inoculation, such as contamination from surgical procedures or penetrating trauma—has been noted [1]. Clinically and histopathologically, musculoskeletal infections caused by NTM resemble those caused by Mycobacteria tuberculosis; however, they are largely resistant to routine anti-tuberculosis agents [3,4]. Therefore, NTM infections can either be missed or even regarded as drug resistant tuberculosis, causing a significant delay in diagnosis. Here, we present the features and outcomes of 6 immunocompetent patients with musculoskeletal infections caused by NTM. We retrospectively analyzed the outcomes of musculoskeletal infections caused by NTM in 6 healthy, immunocompetent hosts admitted between 2004 and 2015. The etiology was traced, and available culture reports were reviewed. NTM inoculation was traced to open fractures in 2 patients (1, patella; 1, humerus), intra-articular injection in 2 patients (1, hip; 1, shoulder), local steroid injection to the calcaneum in 1 patient, and an arthroscopic procedure in the knee joint in 1 patient. Histopathological analyses revealed chronic granulomatous inflammation, with positive NTM cultures. Following radical debridement and targeted antibiotic therapy for NTM, all 6 patients showed complete resolution over a follow-up period of 8 months to 10 years, with no recurrence. NTM are an uncommon pathogen in immunocompetent patients. In patients with chronic granulomatous infection not responding to standard anti-tuberculous treatment and with a history suggestive of inoculation—namely open fractures, surgical intervention, or injection—the possibility of NTM infection should be considered. Appropriate antibiotic therapy based on drug susceptibility reports gives good outcomes. While the hallmark of M. tuberculosis infections is chronic granulomatous inflammation, not every case of mycobacterial granulomatous inflammation is due to M. tuberculosis