The role of outpatient needle arthroscopy in the diagnosis and management of musculoskeletal complaints: A systematic review of the Arthrex NanoScope.

BACKGROUND: The aim was to review the literature regarding needle arthroscopy using the Arthrex NanoScope system and evaluate: (1) the diagnostic indications, utility, and efficacy compared to conventional methods, and (2) the therapeutic indications, safety, and reported outcomes. METHODS: Searches of three databases (MEDLINE, Embase and PubMed) were conducted in November 2021 using MeSH terms: 'needle arthroscopy', 'human', 'in office arthroscopy', 'needle arthroscope', 'nanoscopic', 'surgery', 'nanoscope' and 'percutaneous arthroscopy'. The included studies were catalogued, quality-assessed using Methodological Index for Non-Randomised Studies (MINORS), and analysed using the Cochrane data collection templates for randomised control trials (RCT) and non-randomised control trials (non-RCT). The majority of studies were non-numerical and were examined using qualitative analysis. RESULTS: The search yielded 314 studies, 22 of which were included for analysis. MINORS assessment was applicable to four studies. Mean MINORS was 10.7/16 with the most frequent limitations being lack of unbiased endpoint or sample size calculation. The level of evidence ranged from level IV-V. Diagnostic and therapeutic indications were described in relation to the: knee (n = 10); shoulder (n = 6); foot/ankle (n = 3); elbow (n = 2), and miscellaneous (n = 1). CONCLUSIONS: Needle arthroscopy can augment the diagnostic process in patients presenting with musculoskeletal complaints, and may provide benefits in terms of diagnostic accuracy, cost efficiency, timeliness of investigation, and a visually impactful patient-centred consultation. Therapeutic interventions are reported by a small number of pioneer groups who report some benefits over conventional arthroscopy. The available literature remains small and of low quality, and more evidence is needed with regards to patient selection, efficacy, safety, and cost. LEVEL OF EVIDENCE: Level V (based on the weakest study included in the Systematic Review).

Moving orthopaedic procedures out of the operating theatre:Outpatient needle arthroscopy can reduce cost & waste, and increase inpatient capacity compared to conventional knee arthroscopy.

BACKGROUND: Needle arthroscopy (NA) is an emerging technique that could streamline pathways, facilitate timely care, and reduce service burden. The primary aim was to assess the practical and economic viability of an outpatient NA service. Secondary aims were to assess the relative costs and benefits compared to a conventional arthroscopy (CA) service. METHODS: This service feasibility study was conducted between 2021-2022 in a high-volume national treatment centre. A NA pathway was established for patients with chronic soft tissue pathology or early degenerative knee disease. The pathway was evaluated in terms of: i) cost; ii) efficiency, and iii) waste production, and an assessment was conducted of the patient-related and service-related effects. RESULTS: The cost of the NA pathway was £1555.20 per patient, compared to £2,351.53 for CA. Time to management was 45 days for NA versus 180 days for CA. The NA pathway involved two hospital attendances, whereas CA required a minimum of three. NA cases produced 1.4 kg of non-recyclable waste compared to 5.0 kg produced by CA. For every two cases managed by NA instead of CA, capacity for one additional obligate-inpatient procedure was created. CONCLUSIONS: The NA pathway offers a technically and economically viable approach for the management of refractory knee symptoms in the context of chronic soft tissue or early degenerative disease. NA placed less demand on hospital resources, produced two-thirds less non-recyclable waste, and is amenable to a one-stop clinic approach. Clinical studies focused on objective and patient-reported outcome measures are required to assess clinical efficacy.

Computer-assisted measurements of coronal knee joint laxity in vitro are related to low-stress behavior rather than structural properties of the collateral ligaments.

The relationship between coronal knee laxity and the restraining properties of the collateral ligaments remains unknown. This study investigated correlations between the structural properties of the collateral ligaments and stress angles used in computer-assisted total knee arthroplasty (TKA), measured with an optically based navigation system. Ten fresh-frozen cadaveric knees (mean age: 81 ± 11 years) were dissected to leave the menisci, cruciate ligaments, posterior joint capsule and collateral ligaments. The resected femur and tibia were rigidly secured within a test system which permitted kinematic registration of the knee using a commercially available image-free navigation system. Frontal plane knee alignment and varus-valgus stress angles were acquired. The force applied during varus-valgus testing was quantified. Medial and lateral bone-collateral ligament-bone specimens were then prepared, mounted within a uni-axial materials testing machine, and extended to failure. Force and displacement data were used to calculate the principal structural properties of the ligaments. The mean varus laxity was 4 ± 1° and the mean valgus laxity was 4 ± 2°. The corresponding mean manual force applied was 10 ± 3 N and 11 ± 4 N, respectively. While measures of knee laxity were independent of the ultimate tensile strength and stiffness of the collateral ligaments, there was a significant correlation between the force applied during stress testing and the instantaneous stiffness of the medial (r = 0.91, p = 0.001) and lateral (r = 0.68, p = 0.04) collateral ligaments. These findings suggest that clinicians may perceive a rate of change of ligament stiffness as the end-point during assessment of collateral knee laxity.

A comparison of radiological and computer navigation measurements of lower limb coronal alignment before and after total knee replacement.

We compared lower limb coronal alignment measurements obtained pre- and post-operatively with long-leg radiographs and computer navigation in patients undergoing primary total knee replacement (TKR). A series of 185 patients had their pre- and post-implant radiological and computer-navigation system measurements of coronal alignment compared using the Bland-Altman method. The study included 81 men and 104 women with a mean age of 68.5 years (32 to 87) and a mean body mass index of 31.7 kg/m(2) (19 to 49). Pre-implant Bland-Altman limits of agreement were -9.4° to 8.6° with a repeatability coefficient of 9.0°. The Bland-Altman plot showed a tendency for the radiological measurement to indicate a higher level of pre-operative deformity than the corresponding navigation measurement. Post-implant limits of agreement were -5.0° to 5.4° with a repeatability coefficient of 5.2°. The tendency for valgus knees to have greater deformity on the radiograph was still seen, but was weaker for varus knees. The alignment seen or measured intra-operatively during TKR is not necessarily the same as the deformity seen on a standing long-leg radiograph either pre- or post-operatively. Further investigation into the effect of weight-bearing and surgical exposure of the joint on the mechanical femorotibial angle is required to enable the most appropriate intra-operative alignment to be selected.

Enhancing patient recovery following lower limb arthroplasty with a modern wound dressing: a prospective, comparative audit.

OBJECTIVE: To assess current wound care practice, implement a potentially improved regimen and re-evaluate practice. METHOD: Two prospective clinical audits were performed over a 6-month period, involving 100 patients undergoing hip or knee arthroplasty. Fifty consecutive patients with traditional dressings (Mepore; Mölnlycke) were evaluated prior to a change in practice to a modern dressing (Aquacel Surgical; ConvaTec). Fifty consecutive patients were then evaluated with the new dressing to complete the audit cycle. Clinical outcome measures were wear time, number of changes, blister rate and length of hospital stay. Statistical comparisons were performed using Mann Whitney or Fisher's exact test (statistical significance p < 0.05). RESULTS: Wear time for the traditional dressing (2 days) was significantly shorter than for the modern dressing (7 days; p < 0.001), and required more changes (0 vs 3; p < 0.001). Twenty per cent of patients developed blisters with the traditional dressing compared with 4% with the modern dressing (p=0.028). Median length of stay was the same for the modern dressing (4 days) compared with the traditional dressing (4 days). In the modern dressing group, 75% of patients were discharged by day 4, whereas in the traditional group this took until day 6. CONCLUSION: This audit highlights the problems associated with traditional dressings with frequent early dressing changes, blistering and delayed discharge. These adverse outcomes can be minimised with a modern dressing specifically designed for the demands of lower limb arthroplasty. Units planning to implement enhanced recovery regimens should consider adopting this dressing to avoid compromising patient discharge. DECLARATION OF INTEREST: There were no external sources of funding for this audit; however, one author (JC) received reimbursement of expenses to attend and present work at educational conferences from ConvaTec.

Measuring the positional accuracy of computer assisted surgical tracking systems.

Computer Assisted Orthopaedic Surgery (CAOS) technology is constantly evolving with support from a growing number of clinical trials. In contrast, reports of technical accuracy are scarce, with there being no recognized guidelines for independent measurement of the basic static performance of computer assisted systems. To address this problem, a group of surgeons, academics and manufacturers involved in the field of CAOS collaborated with the American Society for Testing and Materials (ASTM) International and drafted a set of standards for measuring and reporting the technical performance of such systems. The aims of this study were to use these proposed guidelines in assessing the positional accuracy of both a commercially available and a novel tracking system. A standardized measurement object model based on the ASTM guidelines was designed and manufactured to provide an array of points in space. Both the Polaris camera with associated active infrared trackers and a novel system that used a small visible-light camera (MicronTracker) were evaluated by measuring distances and single point repeatability. For single point registration the measurements were obtained both manually and with the pointer rigidly clamped to eliminate human movement artifact. The novel system produced unacceptably large distance errors and was not evaluated beyond this stage. The commercial system was precise and its accuracy was well within the expected range. However, when the pointer was held manually, particularly by a novice user, the results were significantly less precise by a factor of almost ten. The ASTM guidelines offer a simple, standardized method for measuring positional accuracy and could be used to enable independent testing of tracking systems. The novel system demonstrated a high level of inaccuracy that made it inappropriate for clinical testing. The commercially available tracking system performed well within expected limits under optimal conditions, but revealed a surprising loss of accuracy when movement artifacts were introduced. Technical validation of systems may give the user community more confidence in CAOS systems as well as highlighting potential sources of point registration error.

Locked intramedullary nailing of symptomatic metastases in the humerus.

The humerus is a common site for skeletal metastases in the adult. Surgical stabilisation of such lesions is often necessary to relieve pain and restore function. These procedures are essentially palliative and should therefore provide effective relief from pain for the remainder of the patient's life without the need for further surgical intervention. We report a retrospective analysis of 35 patients (37 nails) with symptomatic metastases in the shaft of the humerus which were treated by locked, antegrade nailing. There were 27 true fractures (73.0%) and ten painful deposits (27.0%). Relief from pain was excellent in four (11.4%), good in 29 (82.9%) and fair in two (5.7%) on discharge. Function was improved in all but one patient. One case of palsy of the radial nerve was noted. The mean postoperative survival was 7.1 months (0.2 to 45.5) which emphasises the poor prognosis in this group of patients. There were no failures of fixation and no case in which further surgery was required. Antegrade intramedullary nailing is an effective means of stabilising the humerus for the palliative treatment of metastases. It relieves pain and restores function to the upper limb with low attendant morbidity.

A prospective clinical audit of a new dressing design for lower limb arthroplasty wounds.

An audit of wound healing in patients undergoing total hip or knee arthroplasty in a Scottish hospital found that use of a barrier film made no difference to the effectiveness of a new Hydrofiber/hydrocolloid dressing combination.

Heart rate response to egg rotation in the domestic fowl embryo.

1. In eggs turned about 12 times daily, around the long axis of the egg and through about 180 degrees, significant increases in heart rate occurred during turning on the 15th and 17th, although not on the 16th, d of incubation. 2. On and after the 18th d heart rate increases were more marked and occurred both during and after turning. 3. When a single group of embryos was turned every day for the last 4 d of incubation there were significant increases in heart rate on the last 3 d: this repeated retesting had no effect on the response to turning.