Arthroscopy & Soft Tissue Surgery

Arthroscopic management of knee soft tissue injuries, focusing on meniscal repair versus partial meniscectomy and ligamentous reconstruction.

Overview

Arthroscopic primary repair of proximal anterior cruciate ligament tears yields good objective and subjective outcomes at 3.2-year follow-up in a carefully selected population [2]. For isolated tibial avulsion, arthroscopy results in superior outcomes with a reduced incidence of complications compared to open fixation, although mini-open techniques may demonstrate comparable efficacy in certain instances [6].

Conversely, approximately one-third of knee arthroscopies performed for degenerative knee disease are potentially low value care [12]. Patient and/or surgeon preference may play a large role in the decision to perform an arthroscopy without a valid indication [12].

Suggested guidelines for the practice of arthroscopic surgery emphasize the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America [17, 18, 19, 20, 92, 93, 94, 95, 96].

Anatomy & Pathophysiology

Ligamentous

The position of an anterior cruciate ligament (ACL) graft is the most critical surgical variable, directly affecting knee biomechanics and clinical outcomes [28]. Rectangular-tunnel ACL reconstruction more closely resembles normal knee biomechanical behavior than other tunnel shapes [32]. In single-incision arthroscopic ACL replacement, anatomically placed tibial tunnels exhibit abnormal tensile behavior, yet remain compatible with a stable and functional reconstructed knee at 1 year [40].

Fixation protocols for double-bundle ACL grafts can restore knee kinematics without predisposing either graft to failure [25]. While different graft fixation sequences may not produce observable differences in knee kinematics, the sequence alters the in situ forces that grafts bear under knee loading [35]. The double-bundle (DB) technique more consistently reproduces the biomechanical profile of the uninjured limb than the single-bundle (SB) technique, without increasing the risk of over-constraining the knee [42]. However, the effective role of the anatomical double-bundle procedure in better restoring knee kinematics and allowing better clinical outcomes is questionable in an in vivo model [26], [33].

For posterior cruciate ligament (PCL) reconstruction, the double-bundle technique more closely restores the biomechanics of the intact knee than single-bundle reconstruction throughout the range of knee flexion [38]. In combined ACL plus anterolateral-deficient knees, the addition of either anterolateral ligament reconstruction (ALLR) or the modified Ellison procedure restores overall native knee kinematics in a biomechanical in vitro setting [31]. Altering the normal length of the superficial medial collateral ligament results in measurable changes in knee kinematics and stability [24].

Meniscal

Recent studies provide important knowledge about the anatomy, epidemiology, diagnosis, and biomechanical consequences of meniscal ramp lesions, highlighting the importance of careful exploration of the posteromedial part of the knee [34]. No differences in knee joint biomechanics during jogging were observed between the leg that underwent arthroscopic partial meniscectomy (APM) and the control leg [36]. However, knee joint biomechanics exhibited by persons who had undergone APM may explain the morphological degeneration observed at the patellofemoral and tibiofemoral compartments as patients progress from surgery [39].

Kinematics

Subtle scarring of the anterior interval changes the biomechanics of the anterior structures of the knee and may lead to refractory anterior knee pain [27]. Reconstructed knees may be subjected to significantly lower rotational loads compared with the intact knee during maneuvers involving combined in vivo loading [29]. Abnormal knee kinematic patterns in ACL-reconstructed knees emerge during simple, active knee flexion-extension tasks [41]. Patients after ACL reconstruction immersed in a virtual reality environment demonstrated knee joint biomechanics that approximate those of healthy controls [37].

Kinematic implantation of total knee arthroplasty (TKA) appears to achieve acceptable implant biomechanics [43]. Fluoroscopic imaging techniques can accurately measure 6-degree-of-freedom (6DOF) knee kinematics at normal walking speeds [30].

Classification

Arthroscopic surgery has led to the identification of previously unrecognized pathological conditions and significant new information about traditional problems [4]. Arthroscopists should have a low threshold for biopsy examination of abnormal tissue in patients with unusual presentations [3].

Outerbridge: This system was moderately accurate when used to grade chondral lesions arthroscopically [67]. There is a high prevalence of articular cartilage damage, as defined by the Outerbridge classification, in patients undergoing arthroscopic surgery for meniscal pathology [97]. Arthroscopic surgery in selected patients over 50 years of age might be beneficial if classified as Tönnis grade 0 preoperatively and/or classified as Outerbridge grade II in arthroscopic findings [104].

ICRS: The arthroscopic ICRS classification system has good interobserver and intraobserver reliability [87].

Radiographic: The overall estimates with six radiographic classification systems demonstrated moderate (anteroposterior radiographs) to good (45° posteroanterior flexion weight-bearing radiographs) interobserver reliability and medium correlation with arthroscopic findings [88]. No current MRI classification system has been shown to correlate with clinical outcomes after all types of cartilage repair surgery [103].

Medial Meniscal Ramp Tears: A surgically relevant classification system for medial meniscal ramp tears groups tears into 5 distinct types to optimize repair techniques and improve outcomes [62]. This classification system for medial meniscal ramp tears allows for the evaluation of differing repair patterns and their effects on postoperative clinical outcomes [79].

Medial Meniscus Posterior Root Tears (PMMRT): A novel arthroscopic classification of degenerative medial meniscus posterior root tears based on tear gap demonstrated that a higher tear type (increasing displacement of the tear gap) is associated with higher meniscal extrusion, severe chondral wear, and greater severity of arthritis [64]. MRI-based PMMRT classifications show high interobserver agreement, but arthroscopy-validated accuracy evidence remains limited to a single study [80]. No PMMRT classification system can be endorsed as the most robust due to limited arthroscopy-anchored accuracy evidence [80].

Other Considerations: Definitive decisions regarding meniscus repairability are made intraoperatively based on arthroscopic assessment of tear type, location, and vascularity [105].

Clinical Presentation

History and Physical Examination: Diagnosis of plica syndrome relies on clinical history and physical examination [9]. Arthrograms may be beneficial in selected patients, particularly when the diagnosis is unclear or to aid in planning the therapeutic procedure [49].

Imaging and Diagnostic Arthroscopy: Arthroscopy is the gold standard for detecting meniscal tears [49]. Routine diagnostic arthroscopy provides clinically meaningful value only in a subset of patients by identifying pathology not appreciated on MRI [11]. A thorough, standardized, and systematic approach is critical for diagnostic arthroscopy to ensure that no pathology is missed [44]. The use of the flounce sign in routine knee arthroscopy can be helpful, particularly during screening procedures and in exploring tears which are usually not seen easily through routine portals [54]. Arthroscopy has led to the identification of previously unrecognized pathological conditions and significant new information about traditional problems [4].

Specific Pathologies and Presentations: The inferolateral parapatellar synovial fold can cause patellofemoral impingement in both knee joints [1]. Anterior labral tears can present with posterior hip subluxation or dislocation [5]. Subtalar arthroscopy identified pathologies in the subtalar joint in patients with sinus tarsi syndrome [48]. Non-Hodgkin's lymphoma of the knee can present as an unusual presentation diagnosed by arthroscopy [3].

Complications and Utilization: Major complications after knee arthroscopy in children and adolescents are rare, while minor complications are more common [10]. Less than half of people with a meniscal tear present to secondary care and only 22% undergo arthroscopy [52]. Routine pathological examination of surgical specimens from patients undergoing knee arthroscopy had limited cost-effectiveness because of the low prevalence of findings that altered patient management [45].

Investigations

Plain radiography: Clinical examination and plain radiographs are sufficient indications for knee arthroscopy, rendering routine MRI unnecessary [57]. Preoperative radiographic examination is critical for preoperative planning to avoid unnecessary operations, such as intra-articular pull-out of an interference screw after anterior cruciate ligament reconstruction [89].

MRI: MRI has no effect on the decision to perform arthroscopy or on patient outcome [55]. MRI scans are not routinely necessary as an indication for knee arthroscopy, as clinical examination and plain radiographs are sufficient [57]. MRI tends to grade the anterior one-third of meniscal allografts more poorly than second-look arthroscopy [58]. Preoperative MRI underestimates articular cartilage defect size compared with findings at arthroscopic knee surgery [73]. MRI examination techniques are not able to replace arthroscopy for the diagnosis of cartilage damages of the knee joint [68]. There were fewer arthroscopically-confirmed associated lesions in split-depression fractures of the lateral tibial condyle than reported previously in MRI studies [65]. Even in the absence of radiographic osteoarthritis, patients with femoroacetabular impingement have a probability of extensive articular damage confirmed by arthroscopy [99]. Periarticular soft tissue composition, as approximated by MRI analysis, is a better predictor of outcomes following anterior cruciate ligament reconstruction than body mass index [83]. MRI and second-look arthroscopic examinations showed sound evidence of graft healing in medial meniscus allograft transplantation using a modified bone plug technique [84]. MRI at 1 year after surgery demonstrated residual tear evidence for all patients evaluated for meniscus tear repair healing using in-office needle arthroscopy [98].

Ultrasonography: Ultrasonography is an effective alternative to MRI for diagnosing musculoskeletal pathology, offering real-time imaging, excellent soft-tissue contrast, and high spatial resolution without radiation exposure [59].

Other Considerations: Complete arthroscopic removal of an inferolateral parapatellar synovial fold causing patellofemoral impingement resulted in the patient becoming asymptomatic with no recurrence [1]. Arthroscopists should maintain a low threshold for biopsy examination of abnormal tissue in patients with unusual presentations, such as non-Hodgkin's lymphoma of the knee [3]. Arthroscopic intervention is an appropriate modality for addressing anterior labral tears with posterior hip subluxation or dislocation in patients with continued symptoms [5]. Routine diagnostic arthroscopy may provide clinically meaningful value only in a subset of pediatric and adolescent patients by identifying pathology not appreciated on magnetic resonance imaging (MRI) before medial patellofemoral ligament reconstruction [11]. Patterns of diagnostic imaging, sex proportions, and predominance of arthroscopic techniques for femoroacetabular impingement are consistent worldwide [15]. Interobserver variance exists in diagnostic arthroscopy of the knee, which should be considered when comparing arthroscopic findings with other imaging techniques and when relying on arthroscopic pictures for medical expert witness testimony [61]. In-office small-bore needle arthroscopy offers a cost-effective, safer alternative to formal diagnostic arthroscopy and provides improved accuracy compared with MRI for diagnosing intra-articular knee pathology, particularly in difficult cases or when MRI is contraindicated [77]. Arthroscopically assisted procedures for acromioclavicular joint dislocation may identify concomitant injuries not initially seen on imaging or when a complete imaging evaluation is not available [81].

Treatment

Non-Operative

Nonoperative treatment for posterior cruciate ligament injuries should not be extended more than 1 year from injury [86]. Conservative treatment is the first-line treatment for anterior ankle impingement, with surgery indicated only when conservative measures are unsuccessful [78]. Judicious use of nonoperative treatment modalities among patients who would not benefit from nonoperative care is an effective way of reducing healthcare costs prior to arthroscopic rotator cuff repair [101].

Operative

Indications: Arthroscopic intervention is an appropriate modality for addressing pathology in patients with continued symptoms after conservative measures fail [5]. The main indication for hip arthroscopy is femoroacetabular impingement (FAI) [53]. Arthroscopic intervention is a safe and viable treatment option for patients with symptomatic FAI, with patients expecting long-term improvements and high satisfaction at 10 years [63]. Arthroscopic intervention is an appropriate modality for addressing anterior labral tears with posterior hip subluxation or dislocation in patients with continued symptoms [5]. Posterior ankle arthroscopy is a standardized procedure with numerous indications for posterior pathology when conservative measures fail [16]. Arthroscopic debridement for the management of mild to moderate knee osteoarthritis is effective at short-term follow-up in patients who have exhausted conservative care [66].

Surgical Approach / Technique: Arthroscopic primary repair of proximal anterior cruciate ligament tears results in good objective and subjective outcomes at 3.2-year follow-up in a carefully selected population [2]. This repair may involve additional internal bracing [2]. Arthroscopic soft tissue Bankart repair provides good to excellent long-term clinical results with an acceptable recurrence rate in medium-demand patients, such as recreational athletes and laborers, at 5 to 14 years of follow-up [7]. Most patients achieve successful clinically meaningful outcomes after arthroscopic repair of circumferential labral tears at a mean follow-up of approximately 5 years [8]. Complete healing of posterior horn lateral meniscal oblique radial tears (LMORT) was achieved in 80.3% of patients who underwent second-look arthroscopy, with significantly improved patient-reported outcomes postoperatively [75]. Patients who underwent arthroscopic repair of meniscal root tears had lower pain scores than patients receiving conservative treatment in follow-up [76]. Knee arthroscopy is effective in treating patients with symptomatic osteoarthritis and mechanical symptoms using a novel synthetic acellular meniscal scaffold for irreparable partial meniscus tears, with 76% reporting good and excellent results [74]. Arthroscopic resection of synovial plica of the elbow is effective and safe if conservative treatment fails [47]. Arthroscopic excision is the preferred treatment for localized pigmented villonodular synovitis in the anteromedial compartment of the knee associated with cartilage lesions due to its effectiveness and minimal morbidity [56]. Both arthroscopic soft-tissue-only debridement and arthroscopic superior medial angle bony resection are effective and acceptable treatments for scapulothoracic bursitis, with similar outcomes regarding shoulder function, pain, reoperation, and patient satisfaction [72]. Arthroscopy should be considered the routine treatment for septic arthritis of the knee as it is the less invasive method compared to arthrotomy [13]. The utilization of arthroscopy for isolated tibial avulsion resulted in superior outcomes with a reduced incidence of complications compared to open fixation, although mini-open techniques demonstrated comparable efficacy in certain instances [6]. Open debridement and soft tissue release can be an effective salvage procedure to return mobility and function to the knee in select patients where arthroscopic techniques have failed [69].

Implant Selection: Arthroscopic debridement of mild and moderate knee osteoarthritis provides no benefit in decreasing or delaying arthroplasty surgery compared with conservative treatment at 5-year follow-up [70].

Adjuncts: Fibrin glue is a viable non-invasive treatment option for persistent post-arthroscopic knee seromas, though larger studies are needed [90].

Other Considerations: Patient and/or surgeon preference may play a large role in the decision to perform an arthroscopy without a valid indication, with one-third of procedures among patients with degenerative knee disease potentially being low-value care [12]. While evidence supports meniscal repair and conservative treatment, meniscectomy remains overused due to non-scientific factors like technical difficulty, cost, and patient preferences, necessitating critical analysis to reduce unnecessary resections [82]. Suggested guidelines for the practice of arthroscopic surgery emphasize the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America [17, 18, 19, 20].

Complications

General Morbidity: Arthroscopy remains a central component of orthopedic research due to its low risk of complications and low morbidity [14]. In pediatric and adolescent populations, major complications following knee arthroscopy are rare, although minor complications occur with greater frequency [10]. Comparative data indicate that arthroscopic approaches generally yield lower overall complication rates than open techniques; this includes reduced hospital stays and significantly lower complication rates for ankle arthrodesis in osteoarthritis patients [91], as well as lower overall complication rates compared to open elbow debridements [85].

Patellofemoral / Extensor-Mechanism: Complete arthroscopic removal of an inferolateral parapatellar synovial fold causing patellofemoral impingement results in asymptomatic status with no recurrence [1]. Diagnosis of plica syndrome is confirmed via arthroscopy or arthrotomy [9].

Ligamentous / Meniscal / Labral: Arthroscopic primary repair of proximal anterior cruciate ligament tears yields good objective and subjective outcomes at 3.2-year follow-up in carefully selected populations [2]. Arthroscopic soft tissue Bankart repair provides good to excellent long-term clinical results with an acceptable recurrence rate in medium-demand patients, including recreational athletes and laborers [7]. Both arthroscopic and open Bankart procedures cite satisfactory postoperative outcomes and limited complications for anterior shoulder instability [100]. Most patients achieve successful, clinically meaningful outcomes after arthroscopic repair of circumferential labral tears at a mean follow-up of approximately 5 years [8]. Arthroscopic labral resection in the absence of radiographic evidence of arthritis can result in successful outcomes with 10-year follow-up [23].

Bony / Impingement: Arthroscopic surgery for isolated tibial avulsion results in superior outcomes with a reduced incidence of complications compared to open fixation, although mini-open techniques demonstrate comparable efficacy in certain instances [6]. Combined arthroscopy and femoral osteoplasty demonstrates better long-term clinical outcomes and survivorship compared to arthroscopy alone for femoroacetabular impingement surgery [21]. Aggressive early arthroscopic debridement after discovery of moderate to severe heterotopic ossification of the elbow, with the addition of postoperative radiation therapy, has proved effective in addressing this potentially serious complication [110].

Cartilage / Degenerative: Arthroscopic matrix-assisted autologous chondrocyte transplantation offers good and long-lasting results that are stable over time, resulting in a limited number of failures and reinterventions for up to 15 years of follow-up [22]. The routine use of arthroscopy has led to the identification of previously unrecognized pathological conditions and significant new information about traditional problems [4].

Other Considerations: The evidence base highlights the diagnostic utility and specific therapeutic efficacy of arthroscopic interventions across various anatomical sites, ranging from soft tissue repairs to bony procedures, with complication profiles generally favoring arthroscopic over open approaches where direct comparisons were made.

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return. However, staging arthroscopy to evaluate articular cartilage surfaces resulted in a change in treatment plan in 47% of cases [113]. For acute septic arthritis of the native knee, long-term postoperative range of motion was significantly greater following arthroscopic treatment compared to open treatment [102].

Full activity (months): Arthroscopic primary repair of proximal anterior cruciate ligament tears resulted in good objective and subjective outcomes at 3.2-year follow-up in a carefully selected population [2]. Arthroscopic soft tissue Bankart repair may provide good to excellent long-term clinical results with an acceptable recurrence rate in medium-demand patients, including recreational athletes and laborers [7]. Arthroscopic reconstruction of posterolateral injuries provides good clinical and subjective results after a minimum follow-up of 2 years [106]. Both one-incision and two-incision techniques for anterior cruciate ligament reconstruction with patellar tendon graft are comparable in terms of stability and functional outcome at short-term follow-up [108].

Complete recovery / outcome plateau (months): Complete arthroscopic removal of an inferolateral parapatellar synovial fold causing patellofemoral impingement resulted in the patient becoming asymptomatic with no recurrence [1]. Most patients achieved successful clinically meaningful outcomes after arthroscopic repair of circumferential labral tears at a mean follow-up of approximately 5 years [8]. Arthroscopic matrix-assisted autologous chondrocyte transplantation offered good and long-lasting results that were stable over time, with a limited number of failures and reinterventions for up to 15 years of follow-up [22]. Arthroscopic labral resection in the absence of radiographic evidence of arthritis can result in successful outcomes with 10-year follow-up [23]. At a minimum 5-year follow-up, patients with complete capsular closure after hip arthroscopy for femoroacetabular impingement syndrome show superior long-term outcomes and achieve higher rates of meaningful clinical success compared with patients with partial capsular closure [107]. The mean survival time after arthroscopic treatment of osteoarthritis with a defined protocol was 6.8 years, with 40% of patients delaying arthroplasty for a minimum of 10 years [109]. Up to 10 years after surgery, 86% of fresh-frozen meniscal allograft transplants with soft tissue fixation were still in situ, and satisfactory clinical results were present for about 70% of patients [116].

Rehabilitation protocol: Combined arthroscopy and femoral osteoplasty demonstrated better long-term clinical outcomes and survivorship compared to arthroscopy alone for femoroacetabular impingement surgery at long-term follow-up beyond fifteen years [21]. Predictors of poor outcome after surgical treatment of arthrofibrosis following ligament reconstruction were global arthrofibrosis and a greater than 6-month time interval from primary reconstruction and surgical release [114]. There is a variable time-dependent relationship between the timing of knee arthroscopy and the outcome of a subsequent knee arthroplasty, with literature suggesting a delay between three months to one year, though no absolute guidelines exist [115]. Among patients requiring reoperation for intra-articular defects, the average time to reoperation was nearly 5 months shorter for patients receiving arthroscopy than for patients who did not receive arthroscopy [118].

Functional milestones: Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior patient-reported outcomes or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up [119]. Even though the long-term results of surgical treatment for full-thickness articular surface lesions remain unknown, the early results are encouraging [117].

Key Evidence

• [L4] Complete arthroscopic removal of the tissue resulted in the patient becoming asymptomatic with no recurrence. (10.1016/j.arthro.2005.12.041)
• [L3] Arthroscopic primary repair has resulted in good objective and subjective outcomes at 3.2-year follow-up in a carefully selected population. (10.1007/s00167-018-5338-z)
• [L5] Arthroscopists should have a low threshold when deciding on biopsy examination of abnormal tissue in patients with unusual presentations. (10.1016/j.arthro.2006.01.016)
• [L5] The routine use of arthroscopy has led to the identification of previously unrecognized pathological conditions and significant new information about traditional problems. (10.2106/00004623-198365030-00027)
• [L4] Arthroscopic intervention serves as an appropriate modality for addressing this pathology in patients with continued symptoms. (10.1016/j.arthro.2008.04.059)
• [L1] The utilization of arthroscopy resulted in superior outcomes with a reduced incidence of complications, although in certain instances, the mini open technique demonstrated comparable efficacy to arthroscopy. (10.1177/2325967124s00424)
• [L4] Arthroscopic soft tissue Bankart repair may provide good to excellent long-term clinical results with an acceptable recurrence rate in medium-demand patients (recreational athletes and laborers). (10.1177/2325967119881648)
• [L4] Most patients achieved successful clinically meaningful outcomes after arthroscopic repair at a mean follow-up of approximately 5 years. (10.1177/23259671261418674)
• [L4] Diagnosis rests on clinical history and physical examination but is confirmed by arthroscopy or arthrotomy. (10.2106/00004623-198062020-00008)
• [L4] Major complications after knee arthroscopy in children and adolescents are rare, but minor complications are more common. (10.1016/j.arthro.2014.02.028)
• [L4] These results suggest that routine diagnostic arthroscopy may provide clinically meaningful value only in a subset of patients by identifying pathology not appreciated on MRI. (10.1177/23259671261430753)
• [L4] Patient and/or surgeons preference may play a large role in the decision to perform an arthroscopy without a valid indication. (10.1007/s00167-021-06615-7)
• [L3] As arthroscopy is the less invasive method, it should be considered the routine treatment. (10.1007/s00167-015-3659-8)
• [L5] Arthroscopy is scientifically proven, based on evidence, and will remain a central part of orthopedic research due to low risk of complications and low morbidity. (10.1136/jisakos-2017-000156)
• [L4] However, patterns of diagnostic imaging, sex proportions, and predominance of arthroscopic techniques are consistent worldwide. (10.1016/j.arthro.2014.06.008)
• [L5] It emphasizes that while conservative treatment is the initial approach, arthroscopy is a standardized procedure with numerous indications for posterior pathology when conservative measures fail. (10.1136/jisakos-2016-000082)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(14)00453-8)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(18)30012-4)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(15)00394-1)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(16)30959-8)
• [L3] This study demonstrates better long-term clinical outcomes and survivorship with combined arthroscopy and femoral osteoplasty compared to arthroscopy alone. (10.1177/2325967121s00608)
• [L4] Arthroscopic MACT offered good and long-lasting results that were stable over time and resulted in a limited number of failures and reinterventions for up to 15 years of follow-up. (10.1177/0363546520949849)
• [L4] Arthroscopic labral resection in the absence of radiographic evidence of arthritis can result in successful outcomes with 10 year follow-up. (10.1016/j.arthro.2008.04.058)
• [L5] Altering the normal ligament length resulted in measurable changes in knee kinematics and stability. (10.1007/s00167-011-1519-8)
• [L5] Both fixation protocols restored knee kinematics without predisposing either graft to failure. (10.1177/0363546507300822)
• [L4] The effective role of the anatomical double-bundle procedure in better restoring knee kinematics should be questioned in an in vivo model. (10.1177/0363546507305677)
• [L4] Subtle scarring of the anterior interval changes the biomechanics of the anterior structures of the knee and may lead to refractory anterior knee pain. (10.1177/0363546508320480)
• [L4] The position of an ACL graft is the most critical surgical variable because it has a direct effect on knee biomechanics and, ultimately, on clinical outcome. (10.1177/0363546505279922)
• [L3] During such maneuvers, the reconstructed knee may be subjected to significantly lower rotational loads compared with the intact knee. (10.1016/j.arthro.2011.06.028)
• [L5] The presented technique can be used to accurately measure the 6DOF knee kinematics at normal walking speeds. (10.1186/1749-799x-4-6)
• [Paper] In a biomechanical in vitro setting, addition of either ALLR or modified Ellison procedure restored overall native knee kinematics in a combined ACL plus anterolateral-deficient knee. (10.1136/jisakos-2019-000360)
• [L5] The RET ACL-reconstructed knee more closely resembled the normal knee in biomechanical behavior. (10.1016/j.arthro.2014.05.027)
• [L4] The effective role of the anatomical double-bundle procedure in better restoring knee kinematics and allowing better clinical outcomes should be questioned in an in vivo model. (10.1177/0363546509339021)
• [L5] Although more research is still necessary, several recent studies have given us important knowledge about the anatomy, epidemiology, diagnosis, and the biomechanical consequences of these tears, highlighting the importance of the careful and systematic exploration of the posteromedial part of the knee. (10.1007/s00167-022-07292-w)
• [L5] While a difference in knee kinematics may not be observable with different graft fixation sequences, fixation sequence can alter the in situ forces that the grafts bear under knee loading. (10.1007/s00167-014-3158-3)
• [L3] Comparing the APM leg and control leg, no differences in knee joint biomechanics during jogging for the variables assessed were observed. (10.1177/0363546517698934)
• [L3] Patients after ACLR immersed in a virtual reality environment demonstrated knee joint biomechanics that approximate those of healthy controls. (10.1007/s00167-014-3374-x)
• [L5] A double-bundle posterior cruciate ligament reconstruction can more closely restore the biomechanics of the intact knee than can the single-bundle reconstruction throughout the range of knee flexion. (10.1177/03635465000280020201)
• [L3] Knee joint biomechanics exhibited by persons who had undergone arthroscopic partial meniscectomy gait may go some way to explaining the morphological degeneration observed at the patellofemoral and tibiofemoral compartments of the knee as patients progress from surgery. (10.1007/s00167-012-2075-6)
• [L3] Abnormal tensile behavior occurred in anatomically placed tibial tunnels and was compatible with a stable and functional reconstructed knee at 1 year. (10.1177/03635465990270030301)
• [L4] This study demonstrates that abnormal knee kinematic patterns in ACLR knees emerge during a simple, active knee flexion-extension task that can be performed in an MRI scanner. (10.1177/0363546517724417)
• [L3] The DB technique more consistently reproduced the biomechanical profile of the uninjured limb than did the SB technique without increasing the risk of over-constraining the knee. (10.1007/s00167-010-1247-5)
• [Paper] Kinematic implantation of TKA can be done reliably at a low cost and appears to achieve acceptable implant biomechanics. (10.1016/j.otsr.2020.102773)
• [Paper] A thorough, standardized, and systematic approach is critical for diagnostic arthroscopy to ensure that no pathology is missed. (10.1016/j.eats.2013.07.012)
• [L3] Routine pathological examination of surgical specimens from patients undergoing knee arthroscopy had limited cost-effectiveness because of the low prevalence of findings that altered patient management. (10.2106/jbjs.m.01083)
• [L4] The arthroscopic resection is effective and safe if conservative treatment fails. (10.1302/2058-5241.5.200027)
• [L4] Subtalar arthroscopy identified pathologies in the subtalar joint in patients with STS and showed that treatment of these pathologies led to improved function. (10.1016/j.arthro.2008.05.007)
• [L5] Arthrograms can be beneficial in a selected group of patients, particularly when the diagnosis is not clear or if it will help in planning the therapeutic procedure, but may not be necessary when signs and symptoms are clear as arthroscopy is the gold standard. (10.1007/s00167-007-0464-z)
• [Case_report] Arthroscopy is very helpful in treating this condition. (10.1007/s00167-005-0628-7)
• [L3] However, less than half present to secondary care and only 22% undergo arthroscopy. (10.1007/s00167-021-06458-2)
• [L4] The main indication for hip arthroscopy today is FAI. (10.1177/2325967114s00133)
• [L2] Use of this sign in routine knee arthroscopy can be helpful, particularly during screening procedure and in exploring tears which are usually not seen easily through routine portals. (10.1186/s12891-015-0800-2)
• [L1] We found no effect of MRI on the decision to perform arthroscopy or patient outcome. (10.1016/j.arthro.2007.05.020)
• [L4] Arthroscopic excision is the preferred treatment due to its effectiveness and minimal morbidity. (10.1007/s00167-003-0448-6)
• [L3] The data suggests that MRI scans are not routinely necessary as an indication for knee arthroscopy, as clinical examination and plain radiograph are sufficient. (10.1007/s00167-009-0835-8)
• [L3] MRI tended to grade the anterior one-third more poorly than second-look arthroscopy. (10.1016/j.arthro.2014.11.041)
• [L5] Ultrasonography is an effective alternative to MRI for diagnosing musculoskeletal pathology, offering real-time imaging, excellent soft-tissue contrast, and high spatial resolution without radiation exposure, though its utility remains underutilized in orthopaedic surgery compared to other modalities. (10.5435/jaaos-d-16-00221)
• [L4] These results should be considered when comparing arthroscopic findings with other imaging techniques and when relying on arthroscopic pictures for medical expert witness testimony. (10.1007/s001670050066)
• [L4] The system groups tears into 5 distinct types to optimize repair techniques and improve outcomes. (10.1016/j.arthro.2025.03.015)
• [L4] Arthroscopic intervention is a safe and viable treatment option for patients with symptomatic FAI, and patients can expect long-term improvements and high satisfaction. (10.1177/03635465211055485)
• [L3] The classification system demonstrated that a higher tear type (increasing displacement of the tear gap in arthroscopic surgery) is associated with higher meniscal extrusion, severe chondral wear, and greater severity of arthritis. (10.1177/2325967119827945)
• [L2] There were fewer arthroscopically-confirmed associated lesions than reported previously in MRI studies. (10.1302/0301-620x.96b12.34077)
• [L4] Arthroscopic debridement for the management of mild to moderate knee OA is effective at short-term follow-up in patients who have exhausted conservative care. (10.1016/j.arthro.2024.03.016)
• [L5] The Outerbridge classification was moderately accurate when used to grade chondral lesions arthroscopically. (10.1177/03635465030310012601)
• [L2] MRI examination techniques recommended in the literature are not able to replace arthroscopy for the diagnosis of cartilage damages of the knee joint. (10.1007/s00167-003-0393-4)
• [L4] Open debridement and soft tissue release can be an effective salvage procedure to return mobility and function to the knee in select patients where arthroscopic techniques have failed. (10.1177/03635465990270050201)
• [L3] Compared with conservative treatment, arthroscopy provided no benefit in decreasing or delaying arthroplasty surgery. (10.1016/j.arthro.2017.09.023)
• [L3] Both arthroscopic soft-tissue-only debridement and arthroscopic superior medial angle bony resection are effective and acceptable treatments for scapulothoracic bursitis with similar outcomes in regards to shoulder function, pain, reoperation, and patient satisfaction. (10.1177/2325967121s00695)
• [L2] Thus, before arthroscopic surgery, orthopaedic surgeons should consider treatment strategies that are appropriate for a larger defect than predicted by preoperative MRI. (10.1177/0363546512472044)
• [L4] Knee arthroscopy is effective in treating patients with symptomatic osteoarthritis and mechanical symptoms, with 76% reporting good and excellent results. (10.1016/j.arthro.2011.03.031)
• [L4] Complete healing of LMORT was achieved in 80.3% of patients who underwent second-look arthroscopy, and patient-reported outcomes were significantly improved postoperatively. (10.1177/03635465221126506)
• [L3] Patients who underwent arthroscopic repair had lower pain scores than patients with conservative treatment in the follow-up. (10.1186/s12891-024-07359-4)
• [Paper] In-office arthroscopy offers a cost-effective, safer alternative to formal diagnostic arthroscopy and provides improved accuracy compared with MRI for diagnosing intra-articular knee pathology, particularly in difficult cases or when MRI is contraindicated. (10.1016/j.eats.2017.08.044)
• [L5] Conservative treatment is the first-line treatment, with surgery indicated only when conservative measures are unsuccessful. (10.1136/jisakos-2019-000282)
• [L4] This classification system allows for the ability to evaluate differing repair patterns and their effects on postoperative clinical outcomes. (10.1177/2325967125s00101)
• [L2] MRI-based PMMRT classifications show high interobserver agreement, but arthroscopy-validated accuracy evidence remains limited (single study); no system can be endorsed as most robust. (10.1002/ksa.70130)
• [L3] Arthroscopically assisted may have the ability to identify concomitant injuries not initially seen on imaging or when a complete imaging evaluation is not available. (10.1177/2325967125s00151)
• [L5] The paper argues that while evidence supports meniscal repair and conservative treatment, meniscectomy remains overused due to non-scientific factors like technical difficulty, cost, and patient preferences; it calls for a critical analysis of literature to reduce unnecessary resections. (10.1007/s00167-014-3471-x)
• [L3] Periarticular soft tissue composition, as approximated by the novel MRI analysis of this study, is a better predictor of outcomes following ACL reconstruction than is BMI. (10.1007/s00167-018-4966-7)
• [L4] MRI and second-look arthroscopic examinations showed sound evidence of graft healing. (10.1016/j.arthro.2011.02.013)
• [L3] Overall rates of complication were lower following arthroscopic approaches in this cohort of surgeons. (10.1177/23259671261425647)
• [L4] Nonoperative treatment should not be extended more than 1 year from injury. (10.1177/0363546509333479)
• [L4] The arthroscopic ICRS classification system has good interobserver and intraobserver reliability. (10.1016/j.arthro.2016.12.012)
• [L1] The overall estimates with the six radiographic classification systems demonstrated moderate (anteroposterior radiographs) to good (45° posteroanterior flexion weight-bearing radiographs) interobserver reliability and medium correlation with arthroscopic findings. (10.2106/jbjs.m.00929)
• [L4] They emphasize the importance of radiographic examination before arthroscopy to aid in preoperative planning and avoid unnecessary operations. (10.1007/s00167-005-0018-1)
• [L5] Although larger studies are certainly needed, this case suggests fibrin glue is a viable non-invasive treatment option for persistent post-arthroscopic knee seromas. (10.1007/s00167-013-2505-0)
• [L1] However, arthroscopy was associated with a shorter hospital stay and significantly lower overall complication rates compared to open surgery. (10.3390/jcm12103574)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(08)00099-6)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(10)00644-4)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(09)00583-0)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(10)01198-9)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(12)01461-2)
• [L4] This study shows a high prevalence of articular cartilage damage as defined by the Outerbridge classification in patients undergoing arthroscopic surgery for meniscal pathology. (10.1016/j.arthro.2012.02.029)
• [L4] MRI at 1 year after surgery demonstrated residual tear evidence for all patients. (10.1016/j.asmr.2021.08.003)
• [L4] The arthroscopist should inform the patient that even in absence of radiographic OA, the probability of extensive articular damage does exist. (10.1016/j.arthro.2013.09.014)
• [L4] Arthroscopic Bankart and open Bankart were the most commonly reported procedures that cite satisfactory postoperative outcomes and limited complications. (10.1177/2325967118805983)
• [L3] Judicious use of nonoperative treatment modalities among patients who would not benefit from nonoperative care will be an effective way of reducing costs. (10.1177/2325967120937016)
• [L3] Long-term postoperative range of motion was significantly greater following arthroscopic treatment. (10.2106/jbjs.16.00110)
• [L1] No current MRI classification system has been shown to correlate with clinical outcomes after all types of cartilage repair surgery. (10.1177/0363546513485931)
• [L4] Arthroscopic surgery performed in selected patients over 50 years of age might be beneficial if classified as Tönnis grade 0 preoperatively and/or classified as Outerbridge grade II in the arthroscopic findings. (10.1186/s13018-016-0504-9)
• [L5] Definitive decisions regarding repairability are made intraoperatively based on arthroscopic assessment of tear type, location, and vascularity. (10.1177/03635465990270022301)
• [L4] The arthroscopic reconstruction of posterolateral injuries provides good clinical and subjective results after a minimum follow up of 2 years. (10.1177/2325967120s00304)
• [L3] At a minimum 5-year follow-up, patients with complete capsular closure after hip arthroscopy for FAIS show superior long-term outcomes and achieve higher rates of meaningful clinical success when compared with patients with partial capsular closure. (10.1016/j.arthro.2021.01.035)
• [L1] Both techniques are comparable in terms of stability and functional outcome at short-term follow-up. (10.1007/s001670050052)
• [L3] The mean survival time after arthroscopic treatment of osteoarthritis with a defined protocol was 6.8 years, with 40% of patients delaying arthroplasty for a minimum of 10 years. (10.1016/j.arthro.2012.08.018)
• [L4] Aggressive early arthroscopic debridement after discovery with the addition of postoperative radiation therapy has proved effective in addressing this potentially serious complication. (10.1016/j.arthro.2013.03.050)
• [L4] A change in treatment plan was made in 47% of cases in which staging arthroscopy was used to evaluate articular cartilage surfaces. (10.1177/2325967119s00261)
• [L4] Predictors of poor outcome were global arthrofibrosis and greater than 6-month time interval from primary reconstruction and surgical release. (10.1007/s00167-011-1472-6)
• [L5] There is a variable time-dependent relationship between the timing of knee arthroscopy and the outcome of a subsequent knee arthroplasty, with literature suggesting a delay between three months to one year, though no absolute guidelines exist. (10.1016/j.arth.2025.02.004)
• [L4] Up to 10 years after surgery, 86% of fresh-frozen MATs with soft tissue fixation were still in situ, and satisfactory clinical results were present for about 70% of patients. (10.1177/0363546520932923)
• [L5] Even though the long-term results of surgical treatment for full-thickness articular surface lesions remain unknown, the early results are encouraging. (10.5435/00124635-200005000-00005)
• [L3] Among patients requiring reoperation for intra-articular defects, the average time to reoperation was nearly 5 months shorter for patients receiving arthroscopy than for patients who did not receive arthroscopy. (10.1177/2325967119s00325)
• [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)

See Also

• Anterior Cruciate Ligament
• Biomechanics
• Anatomy

References

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[85] Arthroscopic Versus Open Elbow Debridements Among ABOS Part II Candidates: A Decline in Arthroscopic Volume yet Fewer Complications After Arthroscopic Procedures. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261425647

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[90] Fibrin glue as a non‐invasive outpatient treatment for post‐arthroscopic knee seromas. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2505-0

[91] Arthroscopic vs. Open-Ankle Arthrodesis on Fusion Rate in Ankle Osteoarthritis Patients: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2023. DOI: 10.3390/jcm12103574

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