The Use of Telesurgery Mentoring and Augmented Reality to Teach Arthroscopy.

Surgical teaching methods may be enhanced with telesurgery mentoring technology through virtual, visual, and audio interactions in the operating room, irrespective of geographic restrictions. The use of telesurgery mentoring carries the potential for accelerated learning in arthroscopic and surgical education. A telesurgery platform enables the establishment of a global network of surgeons with the goal of bridging gaps in surgical training via an accessible, cost-effective communication pathway. Specifically, such a platform allows a local surgeon to deliver real-time and live virtual assistance to a remote surgeon over a standard internet connection and removes the geographic barriers that prevent the practice of high-quality surgical care, thereby expanding virtual surgical collaboration. The purpose of our study is to describe our technique of telesurgery mentoring using a telesurgery internet platform (SurgTime; www.surgtime.com) and its applicability to teaching arthroscopic surgery skills both within the United States and in developing countries across the globe.

Cost Effective Technique of Shoulder Arthroscopy Without the Use of Epinephrine in Irrigation Solution.

Arthroscopic surgery of the shoulder joint and the subacromial space requires adequate visualization to be effectively performed. Visual clarity is essential to perform a safe and successful arthroscopic procedure. The major determinants to provide visualization in the subacromial space and the glenohumeral joint include adequate inflow (dependent on the dimension of the inflow cannula), flow rate versus pressure, pump system versus gravity, the use of electrocautery and radiofrequency devices, blood pressure control and hypotensive anesthesia, and the type of irrigation solution used with or without the use of epinephrine. In 2012, the cost of a 30-mL (30-mg) vial of epinephrine was $6 (adrenalin/epinephrine injection, USP, Par Pharmaceuticals), and approximately 3 to 4 bottles would be used on average for a single shoulder arthroscopy. In 2019, the same 30-mL bottle of epinephrine cost $237, a nearly 40-fold increase. The purpose of our study is to describe the various factors and techniques that can be used to maintain visual clarity in shoulder arthroscopy without the use of epinephrine in the irrigation solution and the cost savings associated without the use of epinephrine.

Arthroscopic Repair of Type II SLAP Lesions in Overhead Athletes.

For overhead athletes and, in particular, baseball pitchers, the rates of success and return to play for those who have undergone arthroscopic repair of type II SLAP lesions are poor, ranging from 7% to 62%. The reasons for the poor results and high failure rates in overhead athletes with type II SLAP repairs are multifactorial and are a combination of many factors. These factors include the failure to establish the diagnosis and treat these athletes preoperatively; the inability of the operating surgeon to differentiate normal anatomic variants from pathologic SLAP lesions at the time of surgery; the surgical technique, which may violate the rotator cuff; or the placement of suture anchors, which restricts external rotation and alters overhead throwing mechanics. The proper diagnosis of SLAP lesions can be difficult because SLAP tears rarely occur in isolation and are often associated with other shoulder pathology. A proper history detailing the onset of symptoms and whether there was an acute episode of trauma or a history of repetitive use is critical. It is important to remember that no single physical examination finding is pathognomonic for SLAP tears. When seen in isolation, SLAP tears may mimic impingement syndrome (52%) or even anterior instability (39%). Surgical treatment of type II SLAP lesions should not be undertaken lightly in overhead athletes. If a 3-month rehabilitation period followed by a return to sports over the following 3 months does not allow the athlete to return to his or her preinjury level, diagnostic arthroscopy with SLAP repair is a reasonable option and can yield excellent results using the proper techniques. The technique described in detail in this article and our video can be technically demanding, but with the key points outlined, it can be reproduced and provide excellent results for overhead athletes undergoing SLAP repair. By not violating the rotator cuff, using a mattress configuration and keeping the suture knot away from the articular surface, and by not going anterior to the biceps tendon for repair, external rotation and strength can be preserved, leading to an excellent result with a predictable return to play for overhead athletes.

Knee Arthroscopy: A Diagnostic and Therapeutic Tool for Management of Ochronotic Arthropathy.

The surgical treatment of ochronotic arthropathy remains unclear. Although there is no absolute cure for ochronotic arthropathy, current management typically begins with conservative treatment. Total joint replacement may eventually be necessary for joints that become severely degenerative. Ochronotic arthropathy is present in patients with alkaptonuric ochronosis, which is characterized by dark pigmentation of connective tissue and black discoloration of urine owing to a deficiency of homogentisic acid oxidase. As a result, soft tissues become brittle and subsequently more susceptible to mechanical stress, resulting in articular cartilage degeneration. The diagnosis of ochronotic arthropathy of the knee often occurs intraoperatively after discovery of darkened synovium and black deposits during arthroscopy. The purpose of this article is to describe arthroscopic debridement as an effective treatment option and diagnostic tool for ochronotic arthropathy of the knee after failure of conservative measures.

Avoiding Neurological Complications of Elbow Arthroscopy.

Elbow arthroscopy is an increasingly common procedure performed in orthopaedic surgery. However, because of the presence of several major neurovascular structures in close proximity to the operative portals, it can have potentially devastating complications. The largest series of elbow arthroscopies to date described a 2.5% rate of postoperative neurological injury. All of these injuries were transient nerve injuries resolved without intervention. A recent report of major nerve injuries after elbow arthroscopy demonstrated that these injuries are likely under-reported in literature. Because of the surrounding neurovascular structures, familiarity with normal elbow anatomy and portals will decrease the risk of damaging important structures. The purpose of this Technical Note is to review important steps in performing elbow arthroscopy with an emphasis on avoiding neurovascular injury. With a sound understanding of the important bony anatomic landmarks, sensory nerves, and neurovascular structures, elbow arthroscopy can provide both diagnostic and therapeutic intervention with little morbidity.

Arthroscopic Excision of a Symptomatic Meso-acromiale.

The surgical technique for the management of a symptomatic os acromiale remains unclear. Several operative techniques have been described including open excision, open reduction-internal fixation (ORIF), arthroscopic acromioplasty or subacromial decompression, and arthroscopic excision. There are 4 types of os acromiale, with the meso-acromion being the most common and difficult to treat. The excision of a pre-acromion arthroscopically or in an open manner usually produces satisfactory results. However, the open excision of a meso-acromion can lead to persistent pain and deltoid weakness and atrophy. The management of a meso-acromial fragment with ORIF can also result in persistent pain and deltoid weakness and atrophy with nonunion of the fragments. The purpose of this article is to describe an alternative surgical technique to open excision or ORIF when presented with a symptomatic meso-acromiale.

Interobserver Agreement in the Classification of Partial-Thickness Rotator Cuff Tears Using the Snyder Classification System.

BACKGROUND: At present, there is no widely accepted classification system for partial-thickness rotator cuff tears, and as a result, optimal treatment remains controversial. PURPOSE: To examine the interobserver reliability and accuracy of classifying partial rotator cuff tears using the Snyder classification system. We hypothesized that the Snyder classification would be reproducible with high reliability and accuracy. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Twenty-seven orthopaedic surgeons reviewed 10 video-recorded shoulder arthroscopies. Each surgeon was provided with a description of the Snyder classification system for partial-thickness rotator cuff tears and was then instructed to use this system to describe each tear. Interrater kappa statistics and percentage agreement between observers were calculated to measure the level of agreement. Surgeon experience as well as fellowship training was evaluated to determine possible correlations. RESULTS: A kappa coefficient of 0.512 indicated moderate reliability between surgeons using the Snyder classification to describe partial-thickness rotator cuff tears. The mean correct score was 80%, which indicated "very good" agreement. There was no correlation between the number of shoulder arthroscopies performed per year and fellowship training and the number of correct scores. CONCLUSION: The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears.

Analysis of Low-Field MRI Scanners for Evaluation of Shoulder Pathology Based on Arthroscopy.

BACKGROUND: Many studies have compared the diagnostic capabilities of low-field magnetic resonance imaging (MRI) scanners to high-field MRI scanners; however, few have evaluated the low-field MRI diagnoses compared with intraoperative findings. PURPOSE: To determine the accuracy and sensitivity of low-field MRI scanners in diagnosing lesions of the rotator cuff and glenoid labrum. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Over a 2-year period, MRI examinations without intra-articular contrast were performed on 79 patients for shoulder pathologies using an in-office 0.2-T extremity scanner. The MRI examinations were read by board-certified, musculoskeletal fellowship-trained radiologists. All patients underwent shoulder arthroscopy performed by a single sports fellowship-trained orthopaedic surgeon within a mean time of 56 days (range, 8-188 days) after the MRI examination. The mean patient age was 54 years (range, 18-81 years). Operative notes from the shoulder arthroscopies were then retrospectively reviewed by a single blinded observer, and the intraoperative findings were compared with the MRI reports. RESULTS: For partial-thickness rotator cuff tears, the sensitivity, specificity, positive predictive value, and negative predictive value were 85%, 89%, 79%, and 92%, respectively. For full-thickness rotator cuff tears, the respective values were 97%, 100%, 100%, and 98%. For anterior labral lesions, the values were 86%, 99%, 86%, and 99%, and for superior labral anterior-posterior (SLAP) lesions, the values were 20%, 100%, 100%, and 79%, respectively. CONCLUSION: Low-field MRI is an accurate tool for evaluation of partial- and full-thickness rotator cuff tears; however, it is not effective in diagnosing SLAP lesions. More information is needed to properly assess its ability to diagnose anterior and posterior labral lesions.

Analysis of Low-Field Magnetic Resonance Imaging Scanners for Evaluation of Knee Pathology Based on Arthroscopy.

BACKGROUND: In recent years, few studies have evaluated low-field magnetic resonance imaging (MRI) diagnoses compared with intraoperative findings of the knee. PURPOSE: To determine the accuracy and sensitivity of low-field MRI scanners in diagnosing pathology of the menisci, cruciate ligaments, and osteochondral surfaces. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: MRI examinations without intra-articular contrast were performed on 379 patients for knee pathologies over a 4-year period. The MRI examinations were done using a 0.2-tesla scanner utilizing a dedicated knee coil and read by 1 of 3 board-certified, musculoskeletal fellowship-trained radiologists. Within a mean time of 50 days after MRI, all patients underwent knee arthroscopy performed by 1 of 2 sports fellowship-trained orthopaedic surgeons. Operative notes from the knee arthroscopies were then reviewed by a single independent observer, and the intraoperative findings were compared with the MRI reports. RESULTS: For medial meniscus tears, the sensitivity, specificity, positive predictive value, and negative predictive value were 83%, 81%, 89%, and 71%, respectively. For lateral meniscus tears, the values were 51%, 93%, 84%, and 73%, respectively. For anterior cruciate ligament (ACL) tears, the values were 85%, 94%, 69%, and 97%, respectively. For osteochondral lesions, the values were 8%, 99%, 29%, and 94%, respectively. For posterior cruciate ligament (PCL) tears, the specificity and negative predictive value were 99% and 100%, respectively. CONCLUSION: Low-field MRI was an accurate tool for evaluation of medial meniscus and ACL tears. However, within the study population, it is not as effective in diagnosing lateral meniscus tears and showed a poor ability to detect osteochondral lesions. More information is needed to properly assess its ability to diagnose PCL tears.

Complication of the use of a radiofrequency device in arthroscopic shoulder surgery: second-degree burn of the shoulder girdle.

Radiofrequency ablation (RF) energy devices are increasingly being used in arthroscopic surgery. This is a case report of a 53-year-old man who had second-degree burns of the shoulder and chest wall as a result of fluid overheating due to RF. During an extensive arthroscopic bursal dissection of the left shoulder, the suction device on the RF wand and the valve was left open, allowing fluid to drip onto the chest and arm of the patient. Three days after his surgery, on his first postoperative visit, the dressings were removed, and the patient was noted to have severe blistering on the lateral aspect of his arm and on the anterolateral aspect of his left chest wall. One year after the surgery, he still had residual scarring that was only mildly intermittently pruritic. The use of RF during arthroscopic surgery is very useful clinically; however, it is important to have a strict understanding of the potential hazards the thermal energy can cause to the surrounding soft tissue.

The crank test, the O'Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears.

BACKGROUND: Tears of the superior labrum of the shoulder, anterior to posterior, are difficult to diagnose clinically. PURPOSE: We examined whether the crank or O'Brien tests were reliable tools for detecting glenoid labral tears. STUDY DESIGN: Nonrandomized prospective study. METHODS: Results of diagnostic shoulder arthroscopy were compared with those of the preoperative tests and magnetic resonance imaging for 65 patients who had symptoms of shoulder pain. RESULTS: The crank test result was positive in 29 patients (45%), and the O'Brien test was positive in 41 patients (63%). The crank test had a positive predictive value of 41%, was 56% specific, 46% sensitive, and had a negative predictive value of 61%. The O'Brien test had a positive predictive value of 34%, was 31% specific, 54% sensitive, and had a negative predictive value of 50%. Magnetic resonance imaging had a positive predictive value of 63%, was 92% specific, 42% sensitive, and had a negative predictive value of 83%. CONCLUSIONS: The O'Brien and crank tests were not sensitive clinical indicators for detecting glenoid labral tears and other tears of the anterior and posterior labrum. Results were often falsely positive for patients with other shoulder conditions, including impingement or rotator cuff tears.

Two-versus three-portal technique for routine knee arthroscopy.

The purpose of this study was to compare the results of a two-portal versus a three-portal technique for knee arthroscopy and to determine differences in patient and muscle recovery time and postoperative pain. We prospectively evaluated 16 patients undergoing routine knee arthroscopy in a randomized, double-blinded study. Six patients underwent arthroscopy with the standard three-portal technique, with the superomedial portal established through the vastus medialis obliquus muscle. Ten patients underwent the procedure with only two portals, the anteromedial and anterolateral. A third incision was created in the area of the vastus medialis obliquus muscle, but a portal was not created and the muscle was not violated. The same surgeon performed all procedures. Quadriceps muscle strength, total strength, and Lysholm scores were consistently greater for patients in the two-portal group than for patients in the three-portal group. Patients in the three-portal group returned to work and normal activities at a mean of 19 days after surgery, compared with 9 days for patients in the two-portal group. Standard knee arthroscopy with a two-portal technique does not violate the vastus medialis obliquus muscle and allows an earlier return of quadriceps muscle function and strength, earlier rehabilitation, and a faster return to activity.