Arthroscopy and antibiotics.
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Antibiotic Prophylaxis↗
Biomedical subjects
James H Lubowitz
Publications and source records attributed to James H Lubowitz.
Determination of factors influencing tissue effect of thermal chondroplasty: an ex vivo investigation.
PURPOSE: Scientific investigation of thermal chondroplasty using radiofrequency energy (RFE) is confounded by multiple factors associated with the technique. Our purpose was to determine the relative importance of the following factors on tissue effect (depth of tissue debridement plus depth of underlying cell death) of thermal chondroplasty: probe design, generator power setting, speed, force, and number of passes of the probe over treated tissue. We hypothesized the relative importance of these factors would be (from most to least important) power, passes, speed, force, and design. METHODS: Bovine patellae were treated using monopolar RFE. Sample size was based on a 2-level, half-factorial design. Low and high extremes of the factors tested were power setting (50 W v 110 W), passes (1 v 5), speed (3 mm/sec v 10 mm/sec), force (0.15 N v and 0.59 N), and probe design (electrode protrusion 25 microm v 125 microm). Samples were incubated with cell viability stain and examined using confocal laser microscopy to determine tissue effect. Data were analyzed using multiple regression. RESULTS: All factors that were tested significantly influenced tissue effect (P < .05). Power setting had the greatest effect, followed by design, speed, passes, and force. The following interactions of factors were also significant: design and force, power and passes. The optimal configuration resulting in least tissue effect was a power setting of 50 W, electrode protrusion of 25 microm, speed of 10 mm/sec, 1 pass, and 0.15 N of applied force during treatment, which resulted in a predicted tissue effect of 99 +/- 15 microm. CONCLUSIONS: The least tissue effect of thermal chondroplasty was achieved with lower power using a probe with minimal electrode protrusion while performing a rapid, single, lower force pass of the probe over treated tissue. CLINICAL RELEVANCE: Power and probe design have the greatest influence among the factors tested; selecting these parameters preoperatively could control tissue effect.
Animals↗
What, if any, are the indications for arthroscopic debridement of the osteoarthritic knee?
Arthroscopic debridement is a reliable and effective treatment for knee arthritis in appropriately selected patients. Debridement may include lavage, loose body removal, partial meniscectomy, and/or chondroplasty. Patient selection criteria include acute effusion, well localized joint line tenderness, or catching or locking, often associated with a specific mechanism of injury, patients with imaging studies confirming loose bodies, patients with earlier stages of degenerative joint disease, and patients with realistic understanding that the goal of arthroscopy is to diminish pain and improve function and not to cure their arthritis. Surgeons are cautioned, in patients with an osteoarthritic knee, MRI may be overly sensitive and inadequately specific with regard to correlation between pathologic findings (with the exception of loose bodies) and predictably treatable disease. In conclusion, the authors cite the Arthroscopy Association of North America Position Statement on Osteoarthritis: "There is...sub-group of patients with knee arthritis that can be significantly helped with appropriate arthroscopic surgery."
Arthroscopy↗
Interference screw technique for arthroscopic reduction and internal fixation of compression fractures of the tibial plateau.
Arthroscopic reduction and internal fixation (ARIF) is recommended as state-of-the-art treatment for patients with pure compression fracture of the tibial plateau. We describe a new technique for ARIF of pure compression tibial plateau fractures that uses a cannulated, bioabsorbable interference screw. After a guide pin is placed in the center of the compressed fragment and a tamp is used to elevate the fracture (with bone grafting as desired), the interference screw is advanced over the guide pin, resulting in both elevation and buttressing of the fracture. As compared with previously described techniques in which percutaneous buttress screws were used, ARIF attained with an interference screw via the tibial metaphyseal window allows substantially improved efficiency of surgical steps, improved preservation of the soft tissue envelope, definitive articular reduction under arthroscopic visualization, use of a bioabsorbable implant, and elimination of the need for fluoroscopy.
Arthroscopy↗
Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation.
PURPOSE: The purpose of this study was to compare outcomes of chondroplasty versus microfracture versus osteochondral autologous transplantation (OAT) in patients with osteochondral lesions of the talus (OLT). METHODS: After prospective sample size analysis, patients with symptomatic, recalcitrant Ferkel class 2b, 3, and 4 OLT were randomized to chondroplasty, microfracture, or OAT treatment groups. Outcomes were measured with use of the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHS), the Subjective Assessment Numeric Evaluation (SANE) rating, Numeric Pain Intensity (NPI), and magnetic resonance imaging (MRI). RESULTS: Eleven patients had chondroplasty, 10 ankles (9 patients) had microfracture, and 12 patients had OAT. Mean time to follow-up was 53 months (range, 24 to 119 months). AHS scores showed no differences at 12 and 24 months, and SANE ratings showed no differences at final follow-up. NPI was significantly lower (P < .001) in chondroplasty and microfracture cases as compared with OAT at 24 hours postoperatively. Pearson's correlation analysis demonstrated an inverse relation between microfracture and OAT groups in that better outcome was associated with smaller lesions, compared with the chondroplasty group, which revealed mixed results with no particular trend. MRI revealed incomplete fill and edema after chondroplasty or microfracture and chondral gaps after OAT. CONCLUSION: Our results demonstrate no difference between chondroplasty, microfracture, and OAT with regard to AHS and SANE ratings in patients with OLT. However, NPI at 24 hours postoperatively was significantly lower in patients who had chondroplasty and microfracture. LEVEL OF EVIDENCE: Level I, Therapeutic study, high-quality randomized controlled trial with no statistically significant differences but narrow confidence interval.
Adolescent↗
No-tunnel anterior cruciate ligament reconstruction: the transtibial all-inside technique.
The purpose of this technical note is to describe the transtibial all-inside anterior cruciate ligament (ACL) reconstruction technique. This technique combines the advantages of previously described but technically demanding all-inside ACL reconstruction techniques with the ease and familiarity of transtibial guide pin placement. The all-inside technique uses bone sockets as opposed to bone tunnels in both the femur and the tibia and represents a "no-tunnel" technique. When performed with allograft tissue, the method requires only arthroscopic portals and percutaneous guide pin passage. In such cases, this represents a "no-incision" ACL reconstruction. The technique requires the use of a Dual Retrocutter (Arthrex, Naples, FL). This cannulated drill is placed via the anteromedial arthroscopic portal and threads onto a transtibial, percutaneous, reverse-threaded guide pin. Because the drill is assembled arthroscopically (within the joint), a skin incision is not required. The Dual Retrocutter is capable of retrograde and antegrade drilling. Thus, a single Dual Retrocutter achieves transtibial drilling of both tibial and femoral bone sockets. The transtibial all-inside technique may be performed with the use of any ACL graft option. Graft diameter should equal socket diameter. To prevent the graft from "bottoming-out" during tensioning and fixation, graft length must be less than the sum of combined femoral plus tibial socket lengths plus ACL intra-articular distance. During the learning curve, surgeons may choose to wait until the sockets have been prepared, so that graft length need not be estimated. If the graft is prepared before arthroscopic surgery is performed, a 79-mm graft length could be recommended as ideal. To prepare for graft passage, both femoral and tibial graft passing suture loops must be brought out the anteromedial arthroscopic portal without soft tissue interposition between or within the loops. To prepare for graft fixation, a nitinol wire must be brought into the joint via the transtibial, percutaneous guide pin tract for the purpose of guiding the introduction of a cannulated Retroscrewdriver. All of these goals may be accomplished in a single pass. The graft is fixed with femoral and tibial Retroscrews. Backup fixation is optional and may be achieved by tying sutures over small, percutaneously placed cortical buttons. Advantages of this technique may result from "anatomic" graft fixation at the levels of the femoral and tibial joint lines and from retrograde screw fixation, which may eliminate interference screw divergence and increase graft tension when the retrograde screw is advanced. Additionally, because this technique minimizes skin incisions and eliminates open bone tunnels, patients may experience decreased pain, more rapid return to function, and improved cosmesis.
Anterior Cruciate Ligament↗
An ex vivo thermal chondroplasty model: the association of a char-like layer and underlying cell death.
PURPOSE: The purpose of this study was to evaluate the relation between the char-like layer observed during radiofrequency energy (RFE) treatment of cartilage and the depth of underlying cell death. METHODS: Healthy adult bovine patellae were treated with a monopolar RFE probe ex vivo at generator settings of 20, 30, 40, 50, 60, 80, and 110 in cut mode. The presence or absence of a char-like layer and visual electrical discharge was noted. Treated tissue was incubated with cell viability stain, and the depth of cell death and matrix debridement was measured from confocal laser microscopy images. RESULTS: At generator settings of 60 and above, a char-like layer, electrical discharge, and matrix debridement were consistently observed, and the depth of cell death was significantly less (P < .05) than when these features were not observed (< or =30). Paradoxically, the least depth of cell death did not occur at the lowest generator setting in cut mode. It occurred at a generator setting of 60. An increase in impedance of the system and a decrease in current were also associated with reduced cell death. CONCLUSIONS: In this controlled ex vivo study formation of a char-like layer, visual electrical discharge, increased impedance, and reduced current were associated with less depth of cell death when cartilage was treated with monopolar RFE. CLINICAL RELEVANCE: This study suggests that a char-like layer and electrical discharge during RFE treatment of cartilage may be advantageous because, potentially, these features are associated with less depth of cell death (safety) and greater matrix debridement (efficacy).
Animals↗
Randomize, then consent: a strategy for improving patient acceptance of participation in randomized controlled trials.
When arthroscopic surgeons are attempting to resolve questions of a therapeutic or clinical nature, randomized controlled trials (Level I evidence) are most helpful. However, patients may be reluctant or unwilling to participate in randomized controlled trials. To improve the feasibility of conducting a randomized controlled trial, a strategy for improving patients' willingness to participate is proposed. The strategy is simple: randomize, then consent. This strategy allows for an informed consent process more specifically focused on the specific treatment to which the patient has been assigned. This may be less confusing, daunting, and frightening to patients, who thus may be more willing to participate in the randomized controlled trial. A disadvantage of randomization before consent is that randomization, temporally, is more distant from the actual treatment or intervention. However, randomization before consent may represent a compromise promoting both better quality consent and increased patient willingness to participate in randomized controlled trials.
Arthroscopy↗
Hip arthroscopy: an emerging gold standard.
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Arthroplasty, Replacement, Hip↗
Complications in the treatment of medial and lateral sided injuries of the knee joint.
Complications may result from nonoperative and surgical management of medial or lateral sided knee injuries. Because these injuries are often associated with injury to the medial or lateral meniscus and the anterior or posterior cruciate ligaments (ACL and PCL, respectively), injury to these structures will also be considered. We group these complications in 3 categories: (1) complications associated with either operative or nonoperative management, (2) intraoperative complications, and (3) postoperative complications. Greater understanding of complications of medial and lateral knee ligament injuries may result in improved clinical outcomes.
Anterior Cruciate Ligament Injuries↗
Thermal modification of the lax anterior cruciate ligament using radiofrequency: efficacy or catastrophe?
Alchemists dream of using energy to turn base metal to gold. "Shrinkers" use energy to transform laxity to stability. While alchemists search for the mechanism to achieve their goal, shrinkers have thermal energy (heat) and scientific ground for their pursuit. Without doubt, application of heat to collagen using radiofrequency (RF) results in tissue shrinkage. However, with regard to thermal shrinkage of a lax anterior cruciate ligament (ACL) or ACL graft, indications and techniques, rehabilitation and outcomes require review. Such is the purpose of this article.
Animals↗
Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures.
Arthroscopic reduction and internal fixation (ARIF) of tibial intercondylar eminence fractures is the emerging state-of-the-art. ARIF is recommended for displaced type III fractures and should be considered for all cases of displaced type II fractures. Fractures without displacement after closed reduction require careful evaluation to rule out meniscal entrapment. Subjective results of ARIF are uniformly excellent, despite reports of objective anteroposterior laxity. Early range-of-motion exercises are essential to prevent loss of extension. Repair using nonabsorbable suture fixation, when of adequate strength to allow early range-of-motion, has the advantages of eliminating the risks of comminution of the fracture fragment, posterior neurovascular injury, and need for hardware removal, compared with ARIF using screws.
Anterior Cruciate Ligament↗
Arthroscopic rotator cuff repair: the learning curve.
PURPOSE: The purpose of this study was to answer the question: How many cases are required for a surgeon to become proficient in performing arthroscopic rotator cuff repair? We hypothesize that as surgical experienced is gained, learning can be quantitatively shown by a significant decrease in operative time. TYPE OF STUDY: Prospective case series. METHODS: Rotator cuff repair time (RCRT) in minutes (as well as other time components comprising total surgical time) was recorded for 100 consecutive patients having arthroscopic rotator cuff repair performed by a single surgeon beginning with his first case in private practice. Mean RCRTs for consecutive blocks of 10 cases were compared. Learning is graphically represented by plotting the RCRT by case number and generating a logarithmic trend curve. A best-fit linear equation (y = mx + b) allows comparison of the initial 10 cases with the subsequent 90 cases, where m , the slope, represents the rate of decrease in RCRT (learning). RESULTS: Mean RCRT decreased significantly (P < .05) from the first block of 10 cases to the second block of 10 cases. There were no significant changes in mean RCRT when comparing other consecutive blocks of 10 cases. The slope of the line fitting the first block of 10 cases is -8.75; the slope (m) of the line fitting the subsequent 90 cases is -0.23. There is no significant difference in mean RCRT when cases are stratified by tear size. CONCLUSIONS: Graphic representation of RCRT by case number generates a learning curve whereby learning is quantitatively shown as a significant decrease in operative time as surgical experience is gained. CLINICAL RELEVANCE: Qualification of the learning curve for arthroscopic rotator cuff repair provides a guide for orthopaedic surgeons contemplating the expected time line for acquiring proficiency in this technique.
Arthroscopy↗
Video informed consent improves knee arthroscopy patient comprehension.
PURPOSE: The purpose of this study was to test the hypothesis that video informed consent improves knee arthroscopy patient comprehension and satisfaction compared with traditional verbal informed consent. TYPE OF STUDY: Prospective, randomized controlled trial. METHODS: Consecutive patients having informed consent in preparation for knee arthroscopy by a single surgeon were stratified by educational level < or =12th grade or greater than 12th grade, then randomized to video or traditional verbal informed consent groups. Immediately after the informed consent process, patients completed an outcome questionnaire evaluating comprehension and satisfaction. RESULTS: Patients in the video group showed significantly higher comprehension (78.5%) than patients in the verbal group (65.4%) (P = .00001). In the subgroup with < or = 12th grade education level, the video patients scored 73.1% comprehension and the verbal patients only 54.2% (P = .0011). In the subgroup with greater than 12th grade education level, the video patients scored 82.3% and the verbal patients scored 72.2% (P = .0002). There was no significant difference in subjective self-assessment of satisfaction between groups. CONCLUSIONS: Video informed consent improves knee arthroscopy patient comprehension compared with traditional verbal informed consent. LEVEL OF EVIDENCE: Level I.
Adolescent↗
Understanding evidence-based arthroscopy.
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Abstracting and Indexing↗
Arthroscopic visualization of the posterior compartments of the knee.
PURPOSE: The purpose of this study is to test the hypothesis that the efficacy of routine arthroscopic evaluation of the posterior compartments of the knee outweighs the morbidity or inefficiency. TYPE OF STUDY: Prospective cohort analysis. METHODS: One hundred consecutive knees underwent posteromedial and posterolateral evaluation according to an algorithm designed to maximize efficiency of technique. Loose bodies were defined as expected when preoperative imaging or arthroscopy of the rest of the knee revealed loose bodies. The number of attempts required for visualization or visualization not accomplished, morbidity (subjective femoral condylar scuffing or complications associated with the technique), and findings were recorded. RESULTS: With regard to posteromedial, directly inserting the camera (as opposed to an obdurator) resulted in instrument breakage. In this study, 82% of posteromedial compartments were visualized on the first attempt, and 3% were not visualized. We found that 66% of femoral condyles had no damage, 28% mild, 3% moderate, and 3% severe. Loose bodies were found in 4 of 11 (36%) when expected and 0 of 86 when not expected, a significant difference. Five other posteromedial positive findings were observed. With regard to posterolateral, 93% of compartments were visualized on the first attempt, directly with the camera via the anterolateral portal. All were visualized. We found that 96% of femoral condyles had no damage, 4% mild, and 0% moderate or severe. Damage occurred significantly less frequently than with posteromedial. No findings were noted. CONCLUSIONS: Despite inefficiency, we recommend an obdurator for posteromedial visualization via the anterolateral portal. Posteromedial visualization was associated with morbidity but was efficacious in some cases and is strongly recommended when loose bodies are expected. Posterolateral visualization directly with the camera and via the anterolateral portal is efficient and associated with minimal morbidity but was not efficacious in the cohort evaluated. LEVEL OF EVIDENCE: Level II.
Adolescent↗
Minimally invasive surgery-total knee arthroplasty.
Minimally invasive surgery-total knee arthroplasty (MIS-TKA) requires a skin incision of < or =5 inches (measured with the knee in full extension). A mini midvastus approach limits surgical dissection and resultant soft tissue trauma. The patella is subluxated laterally but not everted . MIS-TKA is technically challenging and instrument dependent. The design of cutting guides, sizers, and retractors must continue to evolve. Prospective, randomized controlled trials are required to test the hypothesis that MIS-TKA results in decreased patient morbidity and outcome equal to or better than traditional TKA. The purpose of this article is to describe the MIS-TKA technique.
Arthroplasty, Replacement↗