Jonathan D. Kosy

The Use of Radiofrequency Energy for Arthroscopic Chondroplasty in the Knee

We present a review of the current literature surrounding the use of radiofrequency energy for arthroscopic chondroplasty in the knee. This review article summarizes basic science, clinical efficacy, and recent advances in the understanding of radiofrequency energy use for the treatment of chondral lesions. Laboratory evidence of increased mechanical stability and decreased release of inflammatory mediators associated with the use of radiofrequency energy chondroplasty is described with clinical evidence of decreased pain and increased functional scores when compared with mechanical chondroplasty. We re-examine concerns about the immediate side effects of radiofrequency energy use, including damage to local structures, in light of new potentially contradictory results, as well as the progression of techniques and probe design. However, although reported complications are few, because the quality of clinical evidence about safety and efficacy remains low, we suggest cautious and judicious use of this technology until future research has clearly defined the long-term clinical outcomes and risks.

The value of magnetic resonance imaging in investigating a painful total knee arthroplasty.

This case describes a rare cause of pain around a total knee arthroplasty and highlights the importance of a structured approach to the investigation of these patients. Magnetic resonance imaging provided detailed information about the cause of pain despite the presence of a prosthetic joint, and the pathology, primary non-Hodgkin lymphoma, was treated without the need for further surgical intervention.

Plain radiographs can be used for routine assessment of ACL reconstruction tunnel position with three-dimensional imaging reserved for research and revision surgery

PurposeThe position of the osseous tunnels and graft during anterior cruciate ligament (ACL) reconstruction has been the subject of multiple studies aiming for either anatomical placement or an alternative. The assessment of these positions, using post-operative imaging, is therefore of interest to the surgeon in both the evaluation of surgical performance and surveillance of potential complications. The purpose of this review is to identify the optimal use of imaging in both the surveillance of clinical practice and in planning revision surgery.MethodsA comprehensive systematic review was performed using Medline and Pubmed searches to identify radiological methods used to assess ACL reconstruction tunnel position. Commonly used methods were identified with correlation to either native anatomy or clinical results.ResultsThe findings suggest that plain radiographs can be used to assess tunnel position and identify grafts that are positioned non-anatomically and may be at increased risk of complications. Computer tomography (CT) offers additional information about the tunnel aperture shape and size that is of importance for revision surgery and research projects whilst magnetic resonance imaging (MRI) provides further assessment of both graft integrity and associated soft tissue damage.ConclusionIn the surveillance of routine clinical practice, plain radiographs are sufficient to define tunnel position. The additional information provided by three-dimensional imaging is only required in revision surgery or research studies.Level of evidenceIV.

Anterior Cruciate Ligament Mechanoreceptors and their Potential Importance in Remnant-Preserving Reconstruction: A Review of Basic Science and Clinical Findings

Abstract Mechanoreceptors, within the anterior cruciate ligament (ACL), are believed to have importance in proprioception, contributing to dynamic knee stability. The potential for reinnervation of the ACL graft is one of the proposed advantages of remnant‐preserving reconstruction. The aim of this review is to summarize advances in the basic science underpinning this function, alongside recent clinical studies, to define the current role for remnant‐preservation. A comprehensive systematic review was performed using PubMed and Medline searches. Studies were analyzed with particular focus placed on the methodology used to either identify mechanoreceptors or test proprioception. Contemporary work, using immunohistological staining, has shown mechanoreceptors primarily within proximity to the bony attachments of the ACL (peripherally in the subsynovial layer). The number of these receptors has been shown to decrease rapidly, following rupture, with adhesion to the posterior cruciate ligament slowing this decline. Recent studies have shown proprioceptive deficits, in both the injured and contralateral knees, with the clinical relevance of findings limited by testing methodology and the small differences found. The advantages of remnant‐preservation, seen primarily in animal studies, have not been shown in systematic reviews or meta‐analysis of clinical studies. The potential for reinnervation of the graft is likely time‐dependent and reliant on continued loading of the remnant. Therefore, current clinical use and future research should focus on preserving remnants within 6 months of injury that remain loaded by adherence to the posterior cruciate ligament. Subsequent testing should account for central neurological changes and focus on clinically relevant outcomes.

Arthroscopic removal of paraglenoid cyst causing quadrilateral space syndrome

We report a case of quadrilateral space syndrome caused by an inferior paraglenoid cyst. This cyst was removed arthroscopically, resulting in a complete resolution of symptoms and a successful return to work and sports.

Complex Regional Pain Syndrome after Total Knee Arthroplasty is Rare and Misdiagnosis Potentially Hazardous—Prospective Study of the New Diagnostic Criteria in 100 Patients with No Cases Identified

Abstract Previous studies suggest that complex regional pain syndrome (CRPS) occurs in up to 21% of patients following total knee arthroplasty (TKA). However, this diagnosis has a substantial impact on the patients management if it is incorrect. We aimed to identify cases, using updated internationally accepted criteria, while investigating potential causes of misdiagnosis. We prospectively studied a consecutive series of 100 primary TKA patients. Each patient was assessed 6‐week post‐TKA. Pain levels were recorded with the presence of symptoms and signs of CRPS (Budapest Diagnostic Criteria) assessed in those with excessive pain. An alternative diagnosis was sought, in these patients, including the presence of neuropathic pain. We found no cases of CRPS (no patients had symptoms or signs in greater than two of four subgroups). Seventeen patients had excessive pain levels (nine had an alternative diagnosis explaining this). The commonest signs were sensory and sudomotor, whereas motor/trophic changes were not seen. Using a previous definition (Orlando Criteria), eight patients may have been diagnosed with CRPS. Over half of the patients with unexplained excessive pain had evidence of neuropathic pain. CRPS is a rare diagnosis following TKA using modern criteria. Isolated signs and symptoms may lead to the overdiagnosis of CRPS in the presence of unexplained pain following TKA. New diagnostic criteria, with strict definitions and treatment algorithms, are now accepted. Delays in managing more common causes (such as neuropathic pain) may negatively affect the patients outcome.