Wide-Awake Needle Arthroscopy of the Anterior Ankle: A Standardized Approach

Over the years, possibilities in ankle arthroscopy have evolved from diagnostic inspection to complex interventional procedures. Further innovation may come from needle arthroscopy, which has improved substantially in image quality in recent years and can now be used for interventional procedures as well. We here present a standardized approach to wide-awake needle arthroscopy of the anterior ankle under local anesthesia. As new needle arthroscopic procedures of the ankle arise, this approach serves to help ensure safe, uniform, and beneficial adoption of this emergent technique.

Fifteen out of 16 elite athletes showed concomitant low-grade cartilage lesions of the ankle with unstable syndesmotic injuries: concerns from a prospective case series

Objectives

This study aimed to determine the incidence rate and characterise the location and severity of cartilage lesions in the ankle in elite athletes undergoing suture-button stabilisation for unstable distal syndesmotic injuries using needle arthroscopic examination. The feasibility and safety of ad hoc needle arthroscopy and its assisted interventions were also assessed.

Methods

This prospective case series included elite athletes undergoing surgical stabilisation between April 2021 and June 2023. Procedures involved suture button fixation and needle arthroscopy, conducted by a single ankle fellow-trained surgeon. Ankle cartilage lesions were graded using the Cheng and Ferkel classification and located using the nine-zone grid. The study followed the STROBE statement.

Results

This study included 16 elite athletes undergoing surgery for distal syndesmotic injuries, with 75% having acute and 25% chronic injuries. Cartilage lesions were prevalent (n=15/16, 94%), mainly at the talar dome (90%), and primarily scored as grade 1 (33%) or grade 2 (67%). Distal tibia cartilage damage occurred in 13% of cases. All patients were diagnosed with an instability of the syndesmosis confirmed through needle arthroscopy and were treated with a suture button (one or two buttons) fixation.

Conclusion

In 15/16 elite athletes with syndesmotic injuries, concomitant ankle cartilage lesions were identified through needle arthroscopy. In addition, most of the lesions were classified as grade 1 or 2, denoting superficial damage. Needle arthroscopic interventions proved feasible and safe for confirming syndesmotic instability and addressing intra-articular pathologies.

Second-Look Arthroscopy Shows Inferior Cartilage after Bone Marrow Stimulation Compared with Other Operative Techniques for Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare cartilage quality after different surgical interventions for osteochondral lesions of the talus (OLT), evaluated by second-look arthroscopy. Secondary aims were to report concomitant diagnoses, and to correlate cartilage quality with clinical and radiological outcomes. This review hypothesizes that the cartilage repair after bone marrow stimulation (BMS) is inferior to the other available treatment options.

METHODS

PROSPERO ID: CRD42022311489. Studies were retrieved through PubMed, EMBASE (Ovid), and Cochrane Library. Studies were included if they reported cartilage quality after second-look investigation after surgical treatment of OLT. The primary outcome measure was the cartilage quality success and failure rates (%) per surgical intervention group. Correlations between the cartilage quality and clinical or radiological outcomes were calculated.

RESULTS

Twenty-nine studies were included, comprising 586 ankles that had undergone second-look arthroscopy on average 16 months after initial surgery. The success rate for BMS was 57% (95% confidence interval [CI] = 48%-65%), for fixation (FIX) 86% (95% CI = 70%-94%), for osteo(chondral) transplantation (OCT) 91% (95% CI = 80%-96%), for cartilage implementation techniques (CITs) 80% (95% CI = 69%-88%), and for retrograde drilling 100% (95% CI = 66%-100%). The success rate of BMS was significantly lower than FIX, OCT, and CIT (P < 0.01). There were no significant differences between other treatment groups. A moderate positive significant correlation between the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society score (ICRS) was found (ρ = 0.51, P < 0.001).

CONCLUSIONS

Successful restoration of cartilage quality was found in the majority of surgically treated OLTs. However, BMS yields inferior cartilage quality compared with FIX, OCT, and CIT. Study Design. Systematic review and meta-analysis. Level of evidence. Level IV, systematic review and meta-analysis.

Consensus on the definition and criteria for failure of surgical treatment in bacterial arthritis of a native joint: An international Delphi study

PURPOSE

The literature presents a wide range of success rates for a single surgical intervention of bacterial-septic-arthritis, and there is a lack of clear criteria for identifying treatment failure and making decisions about reintervention. This Delphi study aims to establish a consensus among an international panel of experts regarding the definition of treatment failure and the criteria for reintervention in case of bacterial arthritis.

METHODS

The conducting and reporting Delphi studies (CREDES) criteria were used. Data from a systematic review was provided as the basis for the study. A list of 100 potential experts were identified. The study was designed and conducted as follows: (I) identification and invitation of an expert panel, (II) informing the participating expert panel on the research question and subject, and (III) conducting two or three Delphi rounds to reach consensus on explicit research items. Potential criteria were rated on a five-point Likert scale.

RESULTS

Sixty orthopaedic experts from nine countries participated in this Delphi study, with 55 completing all three rounds. The mean experience as an orthopaedic surgeon was 15 years (SD ± 9). Strong (96%) consensus was reached on the definition of treatment failure: the persistence of physical signs of arthritis (e.g., pain and swelling) and/or systemic inflammation (e.g., fever and no improvement in CRP) despite surgical and antibiotic treatment. Furthermore, consensus (>80%) was reached on six criteria influencing the decision for reintervention; pain (81%), sepsis (98%), fever (88%), serum CRP (93%), blood culture (82%), and synovial fluid culture (84%).

CONCLUSION

The definition of treatment failure for bacterial arthritis after a single surgical intervention was established through a three-round Delphi study. Additionally, consensus was reached on six criteria that are helpful for determining the need for reintervention. This definition and these criteria may help in the development of clinical guidelines, and will empower physicians to make more precise and consistent decisions regarding reintervention for patients, ultimately aiming to reduce over- and undertreatment and improve patient outcomes.

LEVEL OF EVIDENCE

Level V.

Failure rates in surgical treatment in adults with bacterial arthritis of a native joint: a systematic review of 8,586 native joints

INTRODUCTION

Most adult cases of bacterial-septic-arthritis of a native joint are effectively managed with a single surgical debridement, but some cases may require more than one debridement to control the infection. Consequently, this study assessed the failure rate of a single surgical debridement in adults with bacterial arthritis of a native joint. Additionally, risk factors for failure were assessed.

MATERIALS AND METHODS

The review protocol was registered on PROSPERO (CRD42021243460) before data collection and conducted in line with the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' (PRISMA) guidelines. Multiple libraries were systematically searched to identify articles including patients reporting on the incidence of failure (i.e. persistence of infection requiring reoperation) of the treatment of bacterial arthritis. The quality of individual evidence were assessed using the Quality in Prognosis Studies (QUIPS) tool. Failure rates were extracted from included studies and pooled. Risk factors for failure were extracted and grouped. Moreover, we evaluated which risk factors were significantly associated with failure.

RESULTS

Thirty studies (8,586 native joints) were included in the final analysis. The overall pooled failure rate was 26% (95% CI 20 to 32%). The failure rate of arthroscopy and arthrotomy was 26% (95% CI 19 to 34%) and 24% (95% CI 17 to 33%), respectively. Seventy-nine potential risk factors were extracted and grouped. Moderate evidence was found for one risk factor (synovial white blood cell count), and limited evidence was found for five risk factors (i.e. sepsis, large joint infection, the volume of irrigation, blood urea nitrogen-test, and blood urea nitrogen/creatinine ratio).

CONCLUSION

A single surgical debridement fails to control bacterial arthritis of a native joint in approximately a quarter of all adult cases. Limited to moderate evidence exists that risk factors associated with failure are: synovial white blood cell count, sepsis, large joint infection, and the volume of irrigation. These factors should urge physicians to be especially receptive to signs of an adverse clinical course.

Needle Arthroscopic Inspection and Treatment of (Osteo)chondral Lesions of the Ankle in Unstable Syndesmotic Injuries Treated With Suture Button Fixation: A Standardized Approach

Both acute and chronic syndesmotic injuries are associated with (osteo)chondral lesions of the ankle in at least 1 out of 5 patients. Having a common denominator of an acute traumatic injury being external rotation and forced dorsiflexion, the injury of a combined unstable syndesmotic injury and a potentially present concomitant (osteo)chondral lesion to the ankle warrants a thorough diagnostic and interventional approach. Furthermore, early diagnosis may prevent further damage to the joint through lifestyle changes and increase the chances of successful conservative or surgical treatment, potentially reducing the progression toward end-stage osteoarthritis. Consequently, technological advances and financial considerations have led to the development of a minimally invasive needle arthroscopic inspection and treatment of concomitant (osteo)chondral injuries of the ankle in the combined treatment of unstable syndesmotic injuries with suture button fixation. The present Technical Note describes this innovative minimally invasive assessment and concomitant treatment technique.

Needle Arthroscopy for Osteochondral Lesions of the First Metatarsophalangeal Joint: A Standardized Approach

Cartilage and osteochondral lesions of the first metatarsophalangeal (MTP-1) joint are characterized by pain during weight bearing and walking. The lesions often require surgical intervention(s). Arthroscopic bone marrow stimulation may be considered the preferred operative intervention for small lesions. Technological advances, patient preferences, and economic considerations combine to foster the development of minimally invasive needle arthroscopic procedures. This technical note presents and highlights our minimally invasive surgical technique for needle arthroscopic treatment through bone marrow stimulation for osteochondral lesions of the MTP-1 joint.

Needle Arthroscopy for Bacterial Arthritis of a Native Joint: Surgical Technique for the Shoulder, Elbow, Wrist, Knee, and Ankle Under Local Anesthesia

Suspected bacterial arthritis of a native joint requires urgent management to control potential life-threatening sepsis and limit cartilage damage. Diagnosing bacterial arthritis is often challenging and relies on diagnostic tests with low accuracy. A high threshold for surgery poses a risk of undertreatment, whereas a low threshold for surgery could lead to overtreatment with unnecessary invasive and costly procedures. Surgical lavage through arthroscopy or arthrotomy is generally considered standard treatment. Nowadays, needle arthroscopy provides an alternative and potentially less-invasive approach that can safely lower the surgical threshold. Needle arthroscopy can be performed directly upon presentation at the patient's bedside, as it is well tolerated under local anesthesia. Therefore, this Technical Note presents a stepwise guideline for performing standardized needle arthroscopic lavage in patients with (suspected) bacterial arthritis of the shoulder, elbow, wrist, knee, and ankle.

What are the best diagnostic tests for diagnosing bacterial arthritis of a native joint? : a systematic review of 27 studies

AIMS

This study aimed to answer two questions: what are the best diagnostic methods for diagnosing bacterial arthritis of a native joint?; and what are the most commonly used definitions for bacterial arthritis of a native joint?

METHODS

We performed a search of PubMed, Embase, and Cochrane libraries for relevant studies published between January 1980 and April 2020. Of 3,209 identified studies, we included 27 after full screening. Sensitivity, specificity, area under the curve, and Youden index of diagnostic tests were extracted from included studies. We grouped test characteristics per diagnostic modality. We extracted the definitions used to establish a definitive diagnosis of bacterial arthritis of a native joint per study.

RESULTS

Overall, 28 unique diagnostic tests for diagnosing bacterial arthritis of a native joint were identified. The following five tests were deemed most useful: serum ESR (sensitivity: 34% to 100%, specificity: 23% to 93%), serum CRP (sensitivity: 58% to 100%, specificity: 0% to 96%), serum procalcitonin (sensitivity: 0% to 100%, specificity: 68% to 100%), the proportion of synovial polymorphonuclear cells (sensitivity: 42% to 100%, specificity: 54% to 94%), and the gram stain of synovial fluid (sensitivity: 27% to 81%, specificity: 99% to 100%).

CONCLUSION

Diagnostic methods with relatively high sensitivities, such as serum CRP, ESR, and synovial polymorphonuclear cells, are useful for screening. Diagnostic methods with a relatively high specificity, such as serum procalcitonin and synovial fluid gram stain, are useful for establishing a diagnosis of bacterial arthritis. This review helps to interpret the value of various diagnostic tests for diagnosing bacterial arthritis of a native joint in clinical practice. Cite this article: Bone Joint J 2021;103-B(12):1745-1753.