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Arthroplasty (London, England) Apr 2023This study described a minimally invasive approach for the management of early-stage avascular necrosis of the femoral head, which integrated arthroscopic...
OBJECTIVE
This study described a minimally invasive approach for the management of early-stage avascular necrosis of the femoral head, which integrated arthroscopic intra-articular decompression and core decompression by drilling multiple small holes.
METHOD
A total of 126 patients with 185 hip avascular necrosis were included between March 2005 and January 2008, and the hips were classified, based on the Association Research Circulation Osseous staging system, into stage I (n = 43), stage II (n = 114), and stage III (n = 28). Arthroscopic intra-articular inspection and debridement, along with drilling of multiple small holes for core decompression, were performed. The Modified Harris hip score system and radiographs were used to assess the pre- and post-surgery outcomes.
RESULTS
One hundred and three patients (involving 153 hips) were followed up successfully for an average of 10.7 ± 3.4 years (range: 9-12 years). After surgery, the overall survival rate was 51.6% (79 hips), and the clinical survival rates were 79%, 72%, 52%, 32%, and 10% for patients with stage I, IIa, IIb, IIc, and III, respectively. The outcomes of patients with Association Research Circulation Osseous Stages I or IIA were better than those of other stages, while hips with a large necrotic area had poor results. This approach preserved the original biomechanical strength of the femoral head after core decompression and eliminated arthritis factors in the hip joint.
CONCLUSION
The core decompression with multiple small-size holes is an effective method for treating early-stage avascular necrosis of the femoral head, particularly in those with pathological changes in the hip joint.
LEVEL OF EVIDENCE
Therapeutic study, Level IV.
PubMed: 37004129
DOI: 10.1186/s42836-023-00181-8 -
BMJ Case Reports Apr 2022A man in his late 70s presented to the emergency department endorsing a week of malaise. He was recently hospitalised for 2 days for new back pain and was discharged...
A man in his late 70s presented to the emergency department endorsing a week of malaise. He was recently hospitalised for 2 days for new back pain and was discharged with non-opioid pain medications but continued to seek care as he felt unwell. On presentation, he was afebrile with a leukocytosis. Physical examination revealed a painful left knee with no evidence of trauma. Arthrocentesis revealed purulent fluid with elevated white blood cell consistent with septic arthritis. He was started on broad-spectrum antibiotics and underwent irrigation and synovectomy of the left knee. Aspirate and blood cultures grew Transthoracic echocardiogram showed no vegetations; however, an MRI of lumbar spine showed L2-L3 and L4-L5 osteomyelitis. He was treated with intravenous ceftriaxone for 3 weeks and then oral levofloxacin for 3 weeks, for a total 6 week course of antibiotics.
Topics: Anti-Bacterial Agents; Arthritis, Infectious; Bacteremia; Humans; Male; Osteomyelitis; Streptococcal Infections; Streptococcus agalactiae
PubMed: 35440435
DOI: 10.1136/bcr-2022-249337 -
Antibiotics (Basel, Switzerland) Jul 2023Synovitis, like that associated with chronic bacterial arthritis, is a very rare finding during the implantation of knee endoprostheses. In such cases, we fix the knee...
BACKGROUND
Synovitis, like that associated with chronic bacterial arthritis, is a very rare finding during the implantation of knee endoprostheses. In such cases, we fix the knee prostheses with cement containing two antibiotics and carry out a course of systemic antibiotic administration. The aim was to analyze these cases for incidence, detection of bacteria, risk factors, and outcome.
METHODS
Out of 7534 knee replacements between January 2013 and December 2020, 25 cases were suspected during the surgical procedure to have suffered from bacterial arthritis and were treated accordingly. Total synovectomy was carried out, whereby five intraoperative synovial samples were examined bacteriologically, and the complete synovitis was analyzed histologically. The mean follow-up was 65.3 ± 27.1 (24-85) months.
RESULTS
In nine cases (0.12%), the diagnosis of bacterial arthritis was made histologically and by clinical chemistry (elevated CRP), and in two of these cases, pathogen verification was performed. Eight of these nine patients had previously had injections or surgery associated with the corresponding knee joint or had an underlying immunomodulatory disease. None of the patients developed a periprosthetic infection at a later stage.
CONCLUSION
With an incidence of 0.12%, it is rare to unexpectedly detect bacterial synovitis during surgery. Total synovectomy, use of bone cement with two antibiotics, and immediate systemic antibiotic therapy seem to keep the risk of periprosthetic infection low.
PubMed: 37508249
DOI: 10.3390/antibiotics12071153 -
Trials Mar 2023Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are inflammatory diseases that often affect the wrist and, when affected, can lead to impaired wrist function and...
Arthroscopic synovectomy versus intra-articular injection of corticosteroids for the management of refractory psoriatic or rheumatoid arthritis of the wrist: study protocol for a randomized controlled trial (ARCTIC trial).
BACKGROUND
Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are inflammatory diseases that often affect the wrist and, when affected, can lead to impaired wrist function and progressive joint destruction if inadequately treated. Standard care consists primarily of disease-modifying anti-rheumatic drugs (DMARDs), often supported by systemic corticosteroids or intra-articular corticosteroid injections (IACSI). IACSI, despite their use worldwide, show poor response in a substantial group of patients. Arthroscopic synovectomy of the wrist is the surgical removal of synovitis with the goal to relieve pain and improve wrist function. The primary objective of this study is to evaluate wrist function following arthroscopic synovectomy compared to IACSI in therapy-resistant patients with rheumatoid or psoriatic arthritis. Secondary objectives include radiologic progress, disease activity, health-related quality of life, work participation and cost-effectiveness during a 1-year follow-up.
METHODS
This protocol describes a prospective, randomized controlled trial. RA and PsA patients are eligible with prominent wrist synovitis objectified by a rheumatologist, not responding to at least 3 months of conventional DMARDs and naïve to biological DMARDs. For 90% power, an expected loss to follow-up of 5%, an expected difference in mean Patient-Rated Wrist Evaluation score (PRWE, range 0-100) of 11 and α = 0.05, a total sample size of 80 patients will be sufficient to detect an effect size. Patients are randomized in a 1:1 ratio for arthroscopic synovectomy with deposition of corticosteroids or for IACSI. Removed synovial tissue will be stored for an ancillary study on disease profiling. The primary outcome is wrist function, measured with the PRWE score after 3 months. Secondary outcomes include wrist mobility and grip strength, pain scores, DAS28, EQ-5D-5L, disease progression on ultrasound and radiographs, complications and secondary treatment. Additionally, a cost-effectiveness analysis will be performed, based on healthcare costs (iMCQ questionnaire) and productivity loss (iPCQ questionnaire). Follow-up will be scheduled at 3, 6 and 12 months. Patient burden is minimized by combining study visits with regular follow-ups.
DISCUSSION
Persistent wrist arthritis continues to be a problem for patients with rheumatic joint disease leading to disability. This is the first randomized controlled trial to evaluate the effect, safety and feasibility of arthroscopic synovectomy of the wrist in these patients compared to IACSI.
TRIAL REGISTRATION
Dutch trial registry (CCMO), NL74744.100.20. Registered on 30 November 2020.
CLINICALTRIALS
gov NCT04755127. Registered after the start of inclusion on 15 February 2021.
Topics: Humans; Wrist; Synovectomy; Prospective Studies; Quality of Life; Arthritis, Psoriatic; Arthritis, Rheumatoid; Synovitis; Antirheumatic Agents; Injections, Intra-Articular; Pain; Treatment Outcome; Arthroscopy; Randomized Controlled Trials as Topic
PubMed: 36966310
DOI: 10.1186/s13063-023-07129-y -
The Journal of Arthroplasty Jun 2023Following anterior cruciate ligament (ACL) injury, 20% of patients will develop osteoarthritis. Despite this, there remains a paucity of data describing outcomes of...
BACKGROUND
Following anterior cruciate ligament (ACL) injury, 20% of patients will develop osteoarthritis. Despite this, there remains a paucity of data describing outcomes of total knee arthroplasty (TKA) after prior ACL reconstruction. We aimed to describe survivorships, complications, radiographic results, and clinical outcomes of TKA after ACL reconstruction in one of the largest series to date.
METHODS
We identified 160 patients (165 knees) who underwent primary TKA following prior ACL reconstruction between 1990 and 2016 using our total joint registry. The mean age at TKA was 56 years (range, 29-81), 42% were women, and their mean body mass index was 32. Ninety percent of knees were posterior-stabilized designs. Survivorship was assessed using the Kaplan-Meier method. The mean follow-up was 8 years.
RESULTS
The 10-year survivorships free of any revision and any reoperation were 92 and 88%, respectively. Seven patients were revised for instability (6 global and 1 flexion), 4 for infection, and 2 for other reasons. There were 5 additional reoperations: 3 manipulations under anesthesia, 1 wound debridement, and 1 arthroscopic synovectomy for patellar clunk. Nonoperative complications occurred in 16 patients, 4 of which were flexion instability. Radiographically, all nonrevised knees were well-fixed. Knee Society Function Scores significantly improved from preoperative to 5 years postoperative (P < .0001).
CONCLUSION
Survivorship of TKA in post-ACL reconstruction knees was lower than expected with instability being the most common reason for revision. In addition, the most common nonrevision complications were flexion instability and stiffness requiring manipulations under anesthesia, indicating that achieving soft tissue balance in these knees may be difficult.
Topics: Humans; Female; Adult; Middle Aged; Aged; Aged, 80 and over; Male; Arthroplasty, Replacement, Knee; Anterior Cruciate Ligament; Follow-Up Studies; Knee Joint; Anterior Cruciate Ligament Injuries; Reoperation; Anterior Cruciate Ligament Reconstruction; Treatment Outcome
PubMed: 36801476
DOI: 10.1016/j.arth.2023.02.037 -
BMC Musculoskeletal Disorders Jan 2020Septic arthritis of the elbow joint is a rare condition. Limited data is available on infections of the elbow joint following trauma or prior surgery on this joint. The... (Observational Study)
Observational Study
BACKGROUND
Septic arthritis of the elbow joint is a rare condition. Limited data is available on infections of the elbow joint following trauma or prior surgery on this joint. The aim of this study was to describe the etiology, comorbidities, bacterial spectrum and therapy of secondary purulent elbow infections.
METHODS
Patients treated in our hospital were selected through retrospective chart review between 2006 and 2015. We included all patients with an empyema of the elbow after a trauma or surgical intervention on this joint. 30 patients between 26 and 82 years (mean: 52.47) were included.
RESULTS
Seven patients (23.3%) were female, 23 (76.7%) male. 22 patients (73.3%) had a history of trauma, eight (26.7%) had prior elective surgeries on their elbow. Between one and 25 surgeries (mean: 5.77) were necessary for treatment. In nine patients, debridement and synovectomy were sufficient, eight patients (26.7%) received resection of the elbow joint. One patient was treated with a chronic fistula. In 18 patients (60%), cultures of aspiration/intraoperative swabs were positive for Staphylococcus aureus, four of these were methicillin-resistant. Four patients (13.3%) had positive cultures for Staphylococcus epidermidis, in five patients (16.7%) no bacteria could be cultured.
CONCLUSIONS
Secondary infections of the elbow joint are a rare disease with potentially severe courses, requiring aggressive surgical treatment and possibly severely impacting elbow function. Staphylococcus aureus was the most common bacteria in secondary infections and should be addressed by empiric antibiotic treatment when no suspicion for other participating organisms is present.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anti-Bacterial Agents; Child; Coinfection; Debridement; Elbow Joint; Female; Humans; Male; Middle Aged; Retrospective Studies; Staphylococcal Infections; Staphylococcus aureus; Staphylococcus epidermidis; Young Adult
PubMed: 31954400
DOI: 10.1186/s12891-020-3046-6 -
Infection and Drug Resistance 2022Brucellosis is an endemic systemic infectious disease, the most common complication is bone and joint involvement. Sacroiliac joint infections and spinal joint...
BACKGROUND
Brucellosis is an endemic systemic infectious disease, the most common complication is bone and joint involvement. Sacroiliac joint infections and spinal joint infections commonly affect adults, but ankle infections are extremely rare. We report a case of recurrent ankle arthritis caused by .
CASE PRESENTATION
A 50-year-old Chinese male presented to a local hospital with right ankle pain and limited mobility 23 months ago and underwent a synovectomy of the ankle. Specimen culture revealed brucellosis infection in sheep. The patient came to the department of Orthopaedics of our hospital 18 months ago because his symptoms did not improve. The patient's blood culture of bacteria was negative, the serum Rose-Bengal Plate Agglutination Test was positive, and his erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were significantly elevated. Joint synovial fluid of right ankle was extracted by joint aspiration and sent to the laboratory for real-time polymerase chain reaction (Real-time-PCR) examination, the results showed that there was in the synovial fluid. We concluded that the patient had recurrent ankle arthritis and was treated with doxycycline (0.1 g po bid), rifampicin (0.6 g po qd) and cefotaxime-sulbactam (2.25 g ivgtt q8h) for six weeks during hospitalization. When the patient was discharged, the symptoms were mostly relieved and the inflammatory indicators returned to normal. At following-up 18 months later, the patient had no discomfort in the right ankle and all inflammatory markers were normal.
CONCLUSION
ankle arthritis is a rare but serious complication of adult brucellosis. Clinical manifestations and imaging examinations revealed no obvious specificity. In order to prevent ankle deformities, the dead bone of the ankle should be removed and the joint space cleaned and antibiotic therapy should be administered.
PubMed: 36533253
DOI: 10.2147/IDR.S378035 -
JBJS Essential Surgical Techniques 2022Diffuse tenosynovial giant cell tumor (TGCT), also known as pigmented villonodular synovitis, is a benign, neoplastic disease of the synovium that can lead to joint...
UNLABELLED
Diffuse tenosynovial giant cell tumor (TGCT), also known as pigmented villonodular synovitis, is a benign, neoplastic disease of the synovium that can lead to joint destruction, osteoarthritis, and long-term morbidity. Often, there is extra-articular involvement in the intercondylar notch and posterior soft tissues. A complete anterior and posterior synovectomy of the knee is indicated for treating diffuse TGCT when the anterior and posterior compartments of the knee joint are involved. Additionally, either an anterior or posterior synovectomy may be performed when the TGCT is limited to 1 compartment of the knee. Although an anterior synovectomy is relatively straightforward technically, a posterior synovectomy is challenging because of the presence of the neurovascular and muscular structures, which limit access, and because of the infrequency of the procedure.
DESCRIPTION
The surgical technique for open anterior and posterior knee synovectomy is performed under 1 anesthetic via separate exposures with the patient initially supine and then prone. In cases of focal TGCT, in which both the anterior and posterior compartments are involved, either an anterior or posterior approach can be utilized in isolation to target the affected compartment. The anterior approach is performed via anteromedial parapatellar arthrotomy, with care to preserve the meniscal attachments and ligaments. Once the suprapatellar pouch is visualized, all tissue deep to the quadriceps muscle and tendon, extending around to the femoral periosteum, is excised en bloc. Attention is then turned to the undersurface of the patella, fat pad, distal aspect of the femur, and proximal aspect of the tibia. The tumor may be embedded within the fat pad and must be removed. Any tumor remnants within the medial or lateral gutter or beneath the menisci are excised with use of a standard or pituitary rongeur or curets. The quadriceps tendon, subcutaneous tissue, and skin are closed over a deep drain, and the patient is turned prone and re-prepared for the posterior approach. The posterior synovectomy utilizes an S-shaped incision either superolateral to inferomedial or superomedial to inferolateral, depending on the location of the TGCT. The popliteal artery and vein and the tibial and common peroneal nerves are identified, mobilized, and protected during retraction. This step requires ligating the geniculate and other small branches of the popliteal artery and vein. To expose the posterior femoral condyle, the medial and/or lateral heads of the gastrocnemius must be tagged and released by dividing the myotendinous origin from the posterior aspect of the femur at the proximal extent of the condyle.
ALTERNATIVES
Although surgical resection is the primary treatment for TGCT, nonsurgical alternatives include radiation therapy (either external beam or radiosynoviorthesis) and the use of pharmacologic agents. Radiation therapy is associated with complications such as irreversible skin changes, arthrofibrosis, arthritis, osteonecrosis, and radiation-induced sarcoma. Systemic agents such as tyrosine kinase inhibitors (e.g., nilotinib and imatinib) or agents targeting the CSF-1 (colony-stimulating factor-1) pathway (e.g., pexidartinib and emactuzumab) are active against TGCT. The agents are typically employed in recurrent, advanced, and unresectable situations in which surgical morbidity would outweigh the therapeutic benefit. Aside from open synovectomy, arthroscopic synovectomy-usually anterior-has been utilized by some centers.
RATIONALE
To our knowledge, there is no Level-I study indicating the superiority of 1 surgical technique over the other treatments for diffuse TGCT. Anterior arthroscopic synovectomy, in isolation, for diffuse TGCT has demonstrated recurrence rates as high as 92% to 94%. Recent studies comparing anterior and posterior open and arthroscopic synovectomy have demonstrated mixed results, are limited by being retrospective, and are subject to selection bias because of the open synovectomy being selected for more extensive disease. The mixed results may a result of variation in both tumor size and location about the knee joint. The benefit of an open anterior and posterior synovectomy is that it can provide optimal exposure for large and extra-articular tumor masses that would not be accessible using an arthroscopic approach and allows for complete, gross total excision without morsellization of the tumor. The surgeon must be familiar and facile with vascular dissection techniques, even if the soft tissues surrounding the vascular structures are preserved as much as possible, in an effort to minimize postoperative edema.
EXPECTED OUTCOMES
Open anterior and posterior synovectomy provides improved exposure for large and extra-articular tumor masses and has a 5-year recurrence-free survival of 29% to 33%. Pain associated with diffuse TGCT has been demonstrated to improve in 59% of cases, with swelling reported to improve by 72% in patients following surgical intervention. No significant difference has been reported when comparing open versus arthroscopic synovectomy in terms of arthritic progression, with 8% of patients progressing to a total knee arthroplasty at a mean follow-up of 40 months.
IMPORTANT TIPS
Careful preoperative planning is crucial: note all locations of posteriorly located tumor on magnetic resonance imaging and in relation to anatomic landmarks and neurovascular structures in order to guide dissection.It can be advantageous to have multiple blunt retractor options available when dissecting in tight spaces.Be prepared for vessel ligation with free ties, vessel clips, and additional clamps.The technical ability to dissect and mobilize the popliteal vessels is essential, but this step can be tedious.At the time of incision, preserve the integrity of the popliteal fascia to facilitate a good closure later, as this step avoids the herniation of tissues in the popliteal fossa. Because this fascial tissue is fragile, the use of a monofilament rather than braided suture in addition to the placement of far-near-near-far-type figure-of-8 sutures minimizes the risk of tearing the fascia during reapproximation.To ease retraction of the soft tissues, slightly flex the knee to relax the hamstring and other muscles and neurovascular structures. This will also reduce the risk of a postoperative nerve palsy.Although separate instruments for the anterior and posterior portions of the procedure are not necessary, separate drapes, gown, and gloves and other preoperative preparation should be readied in advance for the second portion of the procedure in order to save operative time.
ACRONYMS & ABBREVIATIONS
PVNS = pigmented villonodular synovitisROM = range of motionMRI = magnetic resonance imagingGastroc = gastrocnemiusPDS = polydioxanone sutureCAM = controlled ankle motionASA = acetylsalicylic acid (aspirin).
PubMed: 36741035
DOI: 10.2106/JBJS.ST.21.00035 -
Journal of Orthopaedic Case Reports 2022Pigmented villonodular synovitis (PVNS) is a rare and benign proliferative lesion affecting synovial lining of joints, bursae, and tendon sheaths. Depending on the...
INTRODUCTION
Pigmented villonodular synovitis (PVNS) is a rare and benign proliferative lesion affecting synovial lining of joints, bursae, and tendon sheaths. Depending on the extent of synovial involvement, two forms are distinguished, diffuse, and localized. Intra-articular localized form of PVNS (LPVNS) presents as a nodular, well circumscribed, pedunculated, or sessile soft-tissue mass.
CASE PRESENTATION
We report a case of an unusual localization of LPVNS in posterior ankle recess in a 42-year-old male with concomitant anterior ankle impingement syndrome. To address both the posterior and the anterior ankle disorders the patient was treated with combined two-portal endoscopic hindfoot approach and anterior ankle arthroscopy within the same operative session. The hindfoot endoscopy encompassed complete removal of the localized mass, partial synovectomy of the area at the base of the lesion, removal of os trigonum, and a loose body impinged in the interval between tibia and fibula. The anterior ankle arthroscopy included removal of the osteophytes from the anterior distal tibia and dorsal talus. Patient continued his normal daily and sporting activities without any restrictions and no recurrence of LPVNS 2 years after the surgery.
CONCLUSION
PVNS is an important clinical entity that should always be thought of as a differential diagnosis when treating patients with ankle disorders. Hindfoot endoscopy, when performed by an experienced ankle surgeon, is a safe and effective procedure for LPVNS of the posterior ankle recess, when deemed amenable to complete resection.
PubMed: 36685350
DOI: 10.13107/jocr.2022.v12.i05.2822 -
Cureus Mar 2021Tuberculosis (TB) infections of the musculoskeletal system are rare. A 77-year-old female with chronic left elbow pain for five months was treated by irrigation and...
Tuberculosis (TB) infections of the musculoskeletal system are rare. A 77-year-old female with chronic left elbow pain for five months was treated by irrigation and debridement of the elbow for a presumed diagnosis of septic arthritis. Her pain and wound condition did not improve, and she was referred to our institution. Plain radiograph and magnetic resonance imaging (MRI) revealed an osteolytic lesion with joint effusion and severe destruction of the elbow joint. We suspected an atypical infection of the elbow due to the chronicity, negative culture results and severe osteoarticular destruction. An open arthrotomy with irrigation and debridement was performed, and the joint was stabilized with a pin and immobilized. A tissue acid-fast bacillus (AFB) stain was positive and culture and polymerase chain reaction (PCR) were also positive. Anti-TB drugs were started for a planned 12-month course, but she developed an adverse drug reaction from the standard regimen and had to be switched to a second-line regimen. The stitches were removed at two weeks and the wound eventually healed. The elbow was immobilized in a posterior slab for six weeks then the pin was removed. At the last follow-up visit seven months after the initial surgery, she had improved, with only mild pain on elbow motion. Her range of motion was 110 degrees of flexion and extension lag of 30 degrees. TB of the elbow is a rare condition. The presentation is insidious and varies, and can be confused with other elbow conditions. Delayed diagnosis can lead to severe joint destruction and poor outcome. The physician should always suspect a TB elbow in cases of chronic elbow pain with synovitis, especially in areas endemic for TB. Joint fluid aspiration and MRI are the most reliable investigations for diagnosis. Anti-TB drugs are the mainstay of treatment. Appropriate surgical interventions such as drainage, synovectomy and reconstructive procedures will often be required. Collaboration between the orthopedist and an infectious specialist is essential for optimal treatment planning.
PubMed: 33842141
DOI: 10.7759/cureus.13765