Arthroscopic washout of the knee: a procedure in decline.

BACKGROUND: Osteoarthritis (OA) of the knee is a chronic, progressive condition which often requires surgical intervention. The evidence for the benefits of arthroscopic debridement or washout for knee OA is weak and arthroscopy is currently only indicated in the UK if there is a history of mechanical locking of the knee. OBJECTIVES: To investigate whether there has been any change in the number of arthroscopies performed in the UK since the 2007 NICE guidance on knee arthroscopy and the 2008 Cochrane review of arthroscopic debridement for OA of the knee. METHODS: We interrogated data from the Hospital Episodes Statistics (HES) database with Office of Population Censuses and Surveys-4 (OPSC-4) codes pertaining to therapeutic endoscopic operations in the 60-74 year old and 75 and over age groups. RESULTS: The number of arthroscopic knee interventions in the UK decreased overall from 2000 to 2012, with arthroscopic irrigations decreasing the most by 39.6 per 100,000 population (80%). However, the number of arthroscopic meniscal resections increased by 105.3 per 100,000 (230%) population. These trends were mirrored in both the 60-74 and 75 and over age groups. CONCLUSIONS: Knee arthroscopy in the 60-74 and 75 and over age groups appears to be decreasing but there is still a large and increasing number of arthroscopic meniscal resections being performed

Treatment of failed articular cartilage reconstructive procedures of the knee: A systematic review

Background: Symptomatic articular cartilage lesions of the knee are common and are being treated surgically with increasing frequency. While many studies have reported outcomes following a variety of cartilage restoration procedures, few have investigated outcomes of revision surgery after a failed attempt at cartilage repair or reconstruction. Purpose: To investigate outcomes of revision cartilage restoration procedures for symptomatic articular cartilage lesions of the knee following a previously failed cartilage reconstructive procedure. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed by use of the PubMed, EMBASE, and MEDLINE/Ovid databases for relevant articles published between 1975 and 2017 that evaluated patients undergoing revision cartilage restoration procedure(s) and reported outcomes using validated outcome measures. For studies meeting inclusion criteria, relevant information was extracted. Results: Ten studies met the inclusion criteria. Lesions most commonly occurred in the medial femoral condyle (MFC) (52.8%), with marrow stimulation techniques (MST) the index procedure most frequently performed (70.7%). Three studies demonstrated inferior outcomes of autologous chondrocyte implantation (ACI) following a previous failed cartilage procedure compared with primary ACI. One study comparing osteochondral allograft (OCA) transplant following failed microfracture (MFX) with primary OCA transplant demonstrated similar clinical outcomes and graft survival at midterm follow-up. No studies reported outcomes following osteochondral autograft transfer (OAT) or newer techniques. Conclusion: This systematic review of the literature reporting outcomes following revision articular cartilage restoration procedures (most commonly involving the MFC) demonstrated a high proportion of patients who underwent prior MST. Evidence is sufficient to suggest that caution should be taken in performing ACI in the setting of prior MST, likely secondary to subchondral bone compromise. OCA appears to be a good revision treatment option even if the subchondral bone has been violated from prior surgery or fracture. </jats:sec

Outerbridge grade IV cartilage lesions in the hip identified at arthroscopy

No abstract available

OPTIMAL SHARING OF SURGICAL COSTS IN THE PRESENCE OF QUEUES

We deal with a cost allocation problem arising from sharing a medical service in the presence of queues. We use a standard queuing theory model in a context with several medical procedures, a certain demand of treatment and a maximum average waiting time guarantee set by the government. We show that sharing the use of an operating theatre to treat the patients of the different procedures, leads to a cost reduction. Then, we compute an optimal fee per procedure for the use of the operating theatre, based on the Shapley value. Afterwards, considering the post-operative time, we characterize the conditions under which this cooperation among treatments has a positive impact on the average post-operative costs. Finally, we provide a numerical example constructed on the basis of real data, to highlight the main features of our model.Surgical Waiting Lists; Queueing Theory; Cost-Sharing Game.

Clinically insignificant association between anterior knee pain and patellofemoral lesions which are found incidentally.

Patellofemoral chondral lesions are frequently identified incidentally during the arthroscopic treatment of other knee pathologies. A role has been described for arthroscopic debridement of such lesions when symptoms are known to originate from pathology of the patellofemoral joint. However, it remains unclear how to manage lesions which are found incidentally whilst tackling other pathologies. The purpose of this study was to establish the strength of association between anterior knee pain and patellofemoral lesions identified incidentally in a typical arthroscopic population. A consecutive series of patients undergoing arthroscopy for a range of standard indications formed the basis of this cross section study. We excluded those with patellofemoral conditions in order to identify patellofemoral lesions which were solely incidental. Pre-operative assessments were performed on 64 patients, where anterior knee pain was sought by three methods: an annotated photographic knee pain map (PKPM), patient indication with one finger and by palpated tenderness. A single surgeon, who was blinded to previous recordings, performed standard arthroscopies and recorded patellofemoral lesions. Statistical correlations were performed to identify the association magnitude. Associations were identified between incidental patellofemoral lesions and tenderness palpated on the medial patella (P=0.007, χ2=0.32) and the quadriceps tendon (P=0.029, χ2=0.26), but these associations were at best fair, which could be interpreted as clinically insignificant. In which case incidental patellofemoral lesions are not necessarily associated with anterior knee pain, we suggest that they could be left alone. This recommendation is only applicable to patellofemoral lesions which are found incidentally whilst addressing other pathology

Surgeon radiation exposure in hip arthroscopy: A prospective analysis

Objectives: Hip arthroscopy is an established field within orthopaedic surgery. The majority of the procedures involve repairs of the acetabular labrum and arthroscopic treatment of femoroacetabular impingement (FAI). The procedures are being performed with increasing frequency annually. Fluoroscopic guidance is recommended during these procedures, and radiation exposure to the surgeon, staff, and patient remains a valid concern. The purpose of this study is to measure radiation exposure to the surgeon during hip arthroscopy and determine if this exposure remains below recommended annual occupational radiation exposure thresholds recommended by the International Committee on Radiological Protection (IRCP). Methods: Prospectively, radiation exposure was measured for a single surgeon at a single outpatient facility for all hip arthroscopic procedures over a three-year period. A radiation dosimeter was worn outside of the surgeon’s chest on the lead apron. Standard pre-operative and intra-operative imaging was used for all patients. Radiation readings were prospectively measured for deep dose equivalent (DDE), lens dose equivalent (LDE), and shallow dose equivalent (SDE). The cumulative radiation exposure was tabulated in millirem (mrem), converted to milli-Sieverts (mSv) (standard measurement used by the IRCP) and then the per-patient exposure calculated as well as annual exposure for 100 hip arthroscopies per year. Results: Between July 2011 and July 2014, 209 patients underwent a total of 280 hip arthroscopy procedures at a single facility by a single surgeon. There were 90 labral repairs, 83 femoroplasties, 26 acetabuloplasties, 66 labral debridements, 8 trochanteric bursectomies, and 7 iliopsoas releases. The cumulative DDE was 183 mrem (1.83 mSv), LDE 183 mrem (1.83 mSv), and SDE 176 mrem (1.76 mSv). The calculated per patient exposure for the surgeon was DDE 0.875 mrem (0.00875 mSv), LDE 0.875 mrem (0.00875 mSv), and SDE 0.842 mrem (0.00843 mSv). Calculated annual exposure for a surgeon performing 100 hip arthroscopies per year are DDE 8.75 mrem (0.0875 mSv), LDE 8.75 mrem (0.0875 mSv), and SDE 8.43 mrem (0.0842 mSv). Conclusion: Hip arthroscopy & hip preservation procedures are being performed with increasing frequency annually. Fluoroscopic guidance is recommended for safe entrance into the central compartment and during various parts of the procedures. Radiation exposure to the surgeon, staff, and patient is a valid concern. The IRCP sets recommended annual safety thresholds for occupational radiation exposure. Current annual safety thresholds are 50,000 mrem (500 mSv) to the hands, 50,000 mrem (500 mSv) to the skin, hands & feet, 15,000 mrem (150 mSv) to the eye, and 30,000 mrem (300 mSv) to the thyroid of healthcare workers. Our study shows surgeon radiation exposure below the annual safety thresholds recommended by the IRCP for 100 cases per year. For surgeons performing more than 100 hip arthroscopic procedures annually, the exposure will be higher. Appropriate safety equipment such as lead aprons, thyroid shields, and leaded glasses are still recommended, especially for high volume hip arthroscopists. © The Author(s) 2015

Bad science concerning NHS competition is being used to support the controversial Health and Social Care Bill

A recent report by LSE academics extolling the benefits of competition between NHS hospitals claims causality where there is none. Allyson Pollock, Alison Macfarlane and Ian Greener argue that the authors engage in data dredging and faulty empirical analysis. In so doing, they sweep aside decades of evidence showing why markets do not work in health services and lend support to an HSC Bill that is inherently dangerous