Recurrent Synovial Chondromatosis of the Finger

Synovial chondromatosis of the finger is a rare metaplasia affecting either the finger joint or the tendon sheath. It is a benign extraosseus cartilage tumor that often occurs in numbers and is not solitary in nature. This accumulation of masses within the finger can lead the patient to seek medical care. Symptoms are often painful and functionally disabling. Although rare, synovial chondromatosis must be considered in the differential diagnosis for patients with multiple lesions or masses within the hand and finger. Patient workup involves advanced imaging, including magnetic resonance imaging, ultrasonography, and computerized tomography. However, the results of these studies may be inconclusive. Conservative management can be discussed with the patient but has proven to be ineffective. Surgical excision is the recommended first-line treatment. Whether the surgery is arthroscopic or open, with or without synovectomy, is at the surgeon's discretion. Mass recurrence after surgery is an unfortunate complication, and subsequent treatment strategies are undefined. Recurrence may not occur at the same anatomical site. This condition can be intra-articular (within the figure joint) or extra-articular (within the tendon sheath or bursa). Revision surgery in the form of open excision with synovectomy is the mainstay of treatment. There have been only a few case reports of synovial chondromatosis involving the finger. This case series and up-to-date review of the literature presents a discussion of current surgical care. [Orthopedics. 2021;44(3):e454-e457.].

Clot waveform analysis for perioperative hemostatic monitoring of arthroscopic synovectomy in a pediatric patient with hemophilia A and inhibitor receiving emicizumab prophylaxis

Emicizumab reduces bleeding in patients with hemophilia A and inhibitors (PwHA-I). Coagulation potential during the perioperative period in emicizumab-treated PwHA-I undergoing surgery remains to be evaluated. We describe a 14-year-old boy with HA-I receiving emicizumab prophylaxis who experienced arthroscopic synovectomy. He was treated with a bolus infusion of recombinant factor VIIa (rFVIIa; 80 μg/kg) immediately before surgery, and treatment continued at the same dose every 3 h on day 1, every 4 h on day 2, and every 6 h on day 3. Treatment with rFVIIa was discontinued on day 4. No perioperative bleeding or thrombotic events were observed. Coagulation potential throughout the perioperative period was retrospectively assessed with an easy-to-use clot waveform analysis (CWA). Measurements from CWA returned to within or near the normal range, suggesting successful hemostatic management. Coagulation potentials assessed by CWA showed a significant correspondence with those from a thrombin generation assay (TGA) that is already in use. CWA and TGA could both provide useful data for assessing coagulation potential in the perioperative hemostatic management of emicizumab-treated PwHA-I.

90Y Radiosynovectomy in Persistent Synovitis Caused by Knee Replacement: Long-Term Outcome

INTRODUCTION

After knee replacement, therapy resistant, persistent synovitis is a common issue, which causes effusion and pain, and leads to loosing. It has been hypothesized that radiosynovectomy (RSO) is useful in these patients.

MATERIALS AND METHODS

A cohort of 55 patients with 57 knee replacements and persistent synovitis underwent RSO using 4.9 ± 0.24 mCi (182 ± 9 MBq) of Y-citrate. The number of RSOs ranged from 1 to 4. Bone scans before and 3 months after every RSO were performed. Long-term follow-up ranged from 0.8 to 7.6 years with a mean of 23.2 months. For qualitative analysis, an established 4 steps scoring was used. For quantification, the uptake was determined within the Tc-MDP scintigraphy blood pool phase before and after therapy.

RESULTS

Long-term response was in 27% with excellent, 24% good, 30% weak, and 20% no response. The duration of response was 12.0 ± 12.0 months (maximum, 54 months). In patients with repeated treatment, the effect after the first therapy was lesser than in patients who received a single treatment in total. However, 3 months after the last RSO, patients with repeated treatment showed a similar effectiveness than single treated patients. At the end of long-term follow-up, patients with repeated RSOs had a higher effectiveness at similar duration response. In bone scan, 65% of patients showed a reduction of uptake. When comparing subjective and objective response, 78% of patients showed a concordance in both symptoms and scintigraphy. Pilot histological analysis revealed that the synovitis is triggered by small plastic particles.

CONCLUSIONS

We concluded that RSO is an effective therapy in patients with knee replacement and persistent synovitis with high long-term response. Repeated treatment leads to a stronger long-time response.

Post-operative septic arthritis after arthroscopy: modern diagnostic and therapeutic concepts

PURPOSE

Septic arthritis is a significant complication following arthroscopic surgery, with an estimated overall incidence of less than 1%. Despite the low incidence, an appropriate diagnostic and therapeutic pathway is required to avoid serious long-term consequences, eradicate the infection, and ensure good treatment outcomes. The aim of this current review article is to summarize evidence-based literature regarding diagnostic and therapeutic options of post-operative septic arthritis after arthroscopy.

METHODS

Through a literature review, up-to-date treatment algorithms and therapies have been identified. Additionally, a supportive new algorithm is proposed for diagnosis and treatment of suspected septic arthritis following arthroscopic intervention.

RESULTS

A major challenge in diagnostics is the differentiation of the post-operative status between a non-infected hyperinflammatory joint versus septic arthritis, due to clinical symptoms, (e.g., rubor, calor, or tumor) can appear identical. Therefore, joint puncture for microbiological evaluation, especially for fast leukocyte cell-count diagnostics, is advocated. A cell count of more than 20.000 leukocyte/µl with more than 70% of polymorphonuclear cells is the generally accepted threshold for septic arthritis.

CONCLUSION

The therapy is based on arthroscopic or open surgical debridement for synovectomy and irrigation of the joint, in combination with an adequate antibiotic therapy for 6-12 weeks. Removal of indwelling hardware, such as interference screws for ACL repair or anchors for rotator cuff repair, is recommended in chronic cases.

LEVEL OF EVIDENCE

IV.

Arthroscopic treatment of a lipoma arborescens of the elbow: A case report

INTRODUCTION

Lipoma Arborescens is a rare pathology that mainly affects the knee. Occurrences in the elbow are even more uncommon and mainly involve the bicipitoradial bursa.

CASE'S DESCRIPTION

We describe the case of a 54-year-old patient known for rheumatoid arthritis, who consulted for chronic elbow pain associated with swelling and limited extension.

DIAGNOSIS

The diagnosis of a lipoma arborescens of the elbow involving the whole joint was made using magnetic resonance imaging and confirmed during arthroscopy.

INTERVENTIONS

After a failed nonoperative treatment consisting in intra-articular cortisone injections and physiotherapy, the patient underwent arthroscopic synovectomy and arthrolysis.

OUTCOME

At 1-year follow-up, he reported no pain, satisfactory range of motion, and major improvements in clinical scores.

CONCLUSION

This is the first illustrated case report about lipoma arborescens involving the whole elbow joint. Even though it is a rare disease, awareness of its presentation, imaging patterns, and treatment options is therefore important for clinicians, radiologists, and surgeons. In this case, arthroscopic treatment resulted in satisfactory and long-lasting pain relief and functional results. It may be considered as a safe and effective option in case of failed nonoperative measures.

Modified Lateral Approach of the Elbow for Surgical Release and Synovectomy

Elbow stiffness is a common reason for consultation. In recent years, arthroscopic techniques in elbow surgery have progressed, but there are still some contraindications to performance of arthroscopic synovectomy and release in this joint (elbows with anatomic deformity after multiple procedures, malunion, presence of osteosynthesis material, severe stiffness of >80 degrees, instability, or previous transposition of the ulnar nerve). Therefore, knowledge of a safe and reliable open approach to achieve elbow release and/or synovectomy is essential. We report the technical details of the modified lateral approach between extensor carpi radialis brevis and longus muscles, as well as the clinical results of 43 elbow release and/or synovectomy procedures, illustrating its feasibility. The modified lateral approach, providing visual control of the radial nerve and good anterior exposure of the elbow joint, is detailed. From 1994 to 2016, this approach was used in 43 release and/or synovectomy procedures of the elbow in 41 patients, 30 men and 11 women, with a mean age of 40.56 years (range, 17 to 84 y). Using this procedure, 38 elbows (93%) recovered full extension and 5 subtotal extension with an average deficit of 11 degrees (range, 5 to 20 degrees). All elbows were stable. No neurological complications were reported. The modified lateral approach preserves the insertion of the lateral epicondyle muscles that are major dynamic stabilizers and reduces the risk of instability. Initially described for the treatment of radial tunnel syndrome, it should also be recommended for elbow release and synovectomy.

Synovial Myxoma: Found in Canines, Rabbits, and Now Humans Too?: A Case Report

CASE

A 63 year-old woman presented with a multiple-year history of right knee pain and effusions and pain refractory to numerous knee aspirations and an arthroscopic synovectomy. The patient underwent a 2-incision synovectomy and intralesional resection. A pathologic review of the specimens revealed an infiltrative tumor of basophilic, cluster of differentiation 68-positive synovial cells embedded within a myxoid stroma with low proliferative activity, most consistent with a synovial myxoma.

CONCLUSIONS

This case report of a synovial myxoma-a benign, slow growing but locally aggressive mass that is most commonly found in canines-indicates that the lesion may occasionally occur in humans.

Pigmented villonodular synovitis after anterior cruciate ligament reconstruction using active bioprosthetic composite artificial ligament

Pigmented villonodular synovitis (PVNS) is a proliferative disease that develops in the synovium of joints, especially the knee joints. A 52-year-old man visited our hospital with left knee pain, swelling and symptoms of collapse. Twenty-one years earlier, he had undergone anterior cruciate ligament (ACL) reconstruction using an active bioprosthetic composite (ABC) as an artificial ligament. T1 and T2 weighted magnetic resonance imaging of the knee joint showed rupture of the ABC ligament and low signal intensity of hyperplastic synovium. Arthroscopic total synovectomy without ACL reconstruction was performed and the lesion was histopathologically diagnosed as diffuse PVNS. Clinical outcomes included good pain relief and no recurrence of the disease after 5 years of follow-up.

Non-Hodgkin Lymphoma with Synovial Involvement of the Knee

Musculoskeletal involvement occurs in approximately 25% of patients diagnosed with non-Hodgkin lymphoma (NHL). Skeletal involvement is typically secondary, with primary lymphoma of the bone being much rarer. We describe a case in which a 52-year-old man initially presented features suggestive of Lyme arthritis in his left knee. A synovial biopsy performed as part of a synovectomy procedure revealed a proliferative synovium with dense lymphoplasmacytic B cell infiltrate, suggestive of NHL. An inguinal lymph node biopsy was also performed but did not produce results pathologically similar to those of the left knee synovial biopsy.

[Synovial Haemangioma of the Knee - Diagnosis by Magnetic Resonance Imaging]

Synovial hemangioma is a rare nonneoplastic vascular malformation of the synovial membrane described by Bouchut in 1856. Fewer than 200 cases have been described in the literature, corresponding to 1% of all hemangiomas. The presenting symptoms are often non-specific, which often leads to a delay in diagnosis of many years and can result in arthropathy if left undetected. The early diagnosis of a synovial haemangioma is important as recurrent haemarthrosis may lead to irreversible joint damage and chronic inflammatory synovitis. In practice, there is no consensus on the best treatment of synovial hemangiomas in children. Total resection of the tumor can be performed by arthroscopy in localized forms and for small lesions. Open resection associated with synovectomy is necessary when the hemangioma occupies most of synovial membrane.

[Current Options of Rheumatosurgery of the Hand and Wrist]

Rheumatosurgery is a discipline managing the symptoms of rheumatoid arthritis of the musculoskeletal system. In a vast number of patients this disease starts in the wrist and hand. The portfolio of surgical procedures performed on the skeleton and soft tissues in these regions can be divided into two groups that, however, often times overlap in practice. Commonly, a combination of these surgical interventions is used. The surgical management should commence with prophylactic interventions that aim to slow down the development of rheumatoid deformities. These are followed by reconstructive surgery which shall manage the already developed rheumatoid deformities and their complications. The prophylactic interventions include early and late synovectomy, peritenosynovectomy, tenodeses, tendon transpositions and limited arthrodeses. The reconstructive surgery procedures comprise osteotomy, resection procedures, alloplasties, total arthrodesis and tendon reconstructions. Key words: rheumatoid arthritis, rheumatosurgery, hand, wrist.

Arthroscopic Wrist Debridement and Radial Styloidectomy for Advanced Scapholunate Advanced Collapse Wrist: Long-term Follow-up

BACKGROUND

Symptomatic stage 2 or 3 scapholunate advanced collapse (SLAC) wrist is aggressively treated with salvage procedures, such as proximal row carpectomy or partial wrist fusion with resultant pain relief but limited motion. We hypothesize that arthroscopic synovectomy, radial styloidectomy, and neurectomy will preserve wrist motion, relieve pain, and delay or avoid salvage procedures.

METHODS

We evaluated outcomes in 13 wrists through questionnaires and 11 of these through additional physical examination at a mean follow-up of 5.0 years. Eight wrists were stage 2 and 5 were stage 3. Data at final follow-up included mobility/strength measurements, subjective outcome scores (Disabilities of the Arm, Shoulder, and Hand [DASH] and visual analog scale [VAS] pain), patient satisfaction, and return to work statistics.

RESULTS

Patients had an average flexion-extension arc of 88.0° in the treated wrist and an average grip strength that was 95.0% of the contralateral side. No patients required revision surgery at follow-up. The 13 wrists reported an average DASH score of 16.4 and mean VAS pain score at rest and with activity of 17.9 and 31.6, respectively. All patients working prior to the procedure (n = 8) were able to immediately return to work. In all, 84.6% of patients were satisfied.

CONCLUSIONS

The procedure studied may have advantages in relieving pain, while preserving wrist motion for SLAC stage 2 or 3 disease. This procedure does not preclude future salvage procedures in those patients with severe disease who prefer to maintain wrist motion for the short term. Patients experience good functional outcomes with the majority experiencing a reduction in pain with the ability to return to work.

Metal allergy in total-joint arthroplasty: Case report and literature review

RATIONALE

Due to the low incidence and lack of effective diagnostic measures for the diagnosis of metal allergy in patients undergoing total joint arthroplasty (TJA), diagnosis relies mainly on the exclusion of other causes, in particular infection. It remains a relatively unpredictable and poorly understood cause of implant failure. At present, skin patch testing, leukocyte migration inhibition test (LMIT) and lymphocyte transformation tests (LTT) are being commonly used to assess metal hypersensitivity.This report presents both a case and literature review.

PATIENT CONCERNS

A 61-year-old female patient experienced continuous swelling and pain in the right knee joint for 9 months after a right-side total knee arthroplasty (TKA).

DIAGNOSES

We believe this is the case report of metal allergy in TKA. The following were the reasons for this. First, no definite symptoms of infection during revision arthroplasty were observed, but with obvious hyperplasia of synovium. Furthermore, a frozen biopsy revealed an extremely low neutrophil count, which was considered to be caused by chronic inflammation. Second, the results of repeated post-operation reexaminations indicate a clear increase in the number of eosinophils, while no bacteria were found in the tissue bacterial smear performed during the operation. Third, improvements were clearly observed in the patient following synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.

INTERVENTIONS

The patient underwent synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.

OUTCOMES

The patient's right knee remained mildly swollen; however, the pain has been relieved significantly. The range of motion could achieve 0 degrees of extension and 90 degrees of flexion.

LESSONS

No consensus has been reached about the best diagnostic criteria for this disease, and most physicians would consider it to be a possibility when other diseases including periprosthetic joint infection (PJI) have been excluded. Although this case followed the same course, the outcome following synovectomy and anti-anaphylactic treatment further confirmed our hypothesis.

Our Surgical Experience: Open Versus Endoscopic Carpal Tunnel Surgery

Carpal tunnel release is one of the most common hand operations in the United States and every year approximately 500,000 patients undergo surgical release. In this article, we examine the argument for endoscopic carpal tunnel release versus open carpal tunnel release, as well as some of the literature on anatomical variants in the median nerve at the wrist. We further describe the experience of several surgeons in a large academic practice. The goals of this article are to describe key anatomic findings and to present several cases that have persuaded us to favor offering patients open carpal tunnel release.

In vivo confirmation of the reliability of the dorsal tangential view of the wrist

The purpose of the study was to evaluate the reliability of the dorsal tangential view (DTV) of the wrist using direct visualization of the extensor compartments in vivo. Twelve patients with extensor tendon complications [nine patients with extensor synovitis, two patients with isolated extensor pollicis longus (EPL) rupture, one patient with EPL and extensor indicis proprius rupture] after volar plating of a distal radius fracture were enrolled in the study. We obtained DTVs in the operating room before implant removal and explored the extensor compartments during synovectomy or tendon reconstruction to confirm suspected screw penetration. We confirmed screw penetration on 10 patients during exploration of the extensor compartments. DTV was able to detect seven of these dorsal cortex breaches. There were no false positive results, which we had defined as a screw penetrating an extensor compartment preoperatively, but not visible on the DTV. Of these seven breaches, one was in the second compartment, four were in the third compartment, and the remaining two were in the fourth compartment. The DTV is sufficiently reliable to be used routinely to reduce postoperative extensor tendon complications during volar plating of the distal radius.

LEVEL OF EVIDENCE

4 (case series) diagnostic.

[Primary septic arthritis is a rare, atypical manifestation of invasive meningococcal disease]

We present a case report of a 50-year-old man diagnosed with a primary septic arthritis with invasive Neisseria meningitidis serogroup W (MenW) clonal complex 11 identified with culture in blood and synovial fluid. The patient recovered from rapidly instituted relevant antibiotics and synovectomy, but there may be a risk of fatal delayed diagnosis and treatment by an atypical manifestation of invasive meningococcal disease. Invasive MenW disease has been increasing in recent years and has been described with atypical presentations.

Indications for Hip Arthroscopy

CONTEXT

Hip arthroscopy is gaining popularity within the field of orthopaedic surgery. The development and innovation of hip-specific arthroscopic instrumentation and improved techniques has resulted in improved access to the hip joint and ability to treat various hip pathologies.

EVIDENCE ACQUISITION

Electronic databases, including PubMed and MEDLINE, were queried for articles relating to hip arthroscopy indications (1930-2017).

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Initially used as a technique for loose body removal, drainage/debridement of septic arthritis, and treatment of pediatric hip disorders, hip arthroscopy is currently used to treat various hip conditions. The recognition of femoroacetabular impingement (FAI) as a source of hip pain in young adults has rapidly expanded hip arthroscopy by applying the principles of osseous correction that were previously described and demonstrated via an open surgical dislocation approach. Hip pathologies can be divided into central compartment, peripheral compartment, peritrochanteric space, and subgluteal space disorders.

CONCLUSION

Although hip arthroscopy is a minimally invasive procedure that may offer decreased morbidity, diminished risk of neurovascular injury, and shorter recovery periods compared with traditional open exposures to the hip, it is important to understand the appropriate patient selection and indications.

Functional Outcome Following Extensor Synovectomy and Excision of the Distal Ulna in Patients With Rheumatoid Arthritis

We prospectively measured hand and wrist function in rheumatoid patients undergoing excision of the distal ulna. Range of motion, visual analogue pain scores and grip strength were measured in 22 wrists, and the Jebsen hand function test was administered to seven patients, preoperatively and at 3 and 12 months. At 1 year there were improvements in forearm pronation ( P = 0.04), supination ( P = 0.03) and wrist extension ( P = 0.02), but a reduction in flexion ( P = 0.009). Active radial deviation was reduced and ulnar deviation increased. There was a significant improvement in grip strength ( P = 0.05) and reduction in wrist pain ( P = < 0.0001). At 1 year the Jebsen hand function test showed improvements in simulated feeding, stacking checkers, and lifting large empty cans. Excision of the distal ulna in rheumatoid patients results in an improvement in some aspects of hand function.

[Localized pigmented vellonodular sunovitis, cause of knee hemarthrosis]

The pigmented vellonodular sinovitis (PVNS) is benign neoplasm with synovial proliferation and hemosiderin deposit, characterized by large compromising joints, especially the knee. At present, two variants of clinics, the diffuse form (PVNSD) and the localized (PVNSL) are described. Arthroscopic synovectomy and radiosynoviorthesis (RSO) is the treatment that has shown the best functional results. Nuclear magnetic resonance is an appropriate method for conducting the diagnosis of PVNSL.

Boron neutron capture synovectomy (BNCS) as a potential therapy for rheumatoid arthritis: radiobiological studies at RA-1 Nuclear Reactor in a model of antigen-induced arthritis in rabbits

Rheumatoid arthritis is a chronic autoimmune pathology characterized by the proliferation and inflammation of the synovium. Boron neutron capture synovectomy (BNCS), a binary treatment modality that combines the preferential incorporation of boron carriers to target tissue and neutron irradiation, was proposed to treat the pathological synovium in arthritis. In a previous biodistribution study, we showed the incorporation of therapeutically useful boron concentrations to the pathological synovium in a model of antigen-induced arthritis (AIA) in rabbits, employing two boron compounds approved for their use in humans, i.e., decahydrodecaborate (GB-10) and boronophenylalanine (BPA). The aim of the present study was to perform low-dose BNCS studies at the RA-1 Nuclear Reactor in the same model. Neutron irradiation was performed post intra-articular administration of BPA or GB-10 to deliver 2.4 or 3.9 Gy, respectively, to synovium (BNCS-AIA). AIA and healthy animals (no AIA) were used as controls. The animals were followed clinically for 2 months. At that time, biochemical, magnetic resonance imaging (MRI) and histological studies were performed. BNCS-AIA animals did not show any toxic effects, swelling or pain on palpation. In BNCS-AIA, the post-treatment levels of TNF-α decreased in four of six rabbits and IFN-γ levels decreased in five of six rabbits. In all cases, MRI images of the knee joint in BNCS-AIA resembled those of no AIA, with no necrosis or periarticular effusion. Synovial membranes of BNCS-AIA were histologically similar to no AIA. BPA-BNCS and GB-10-BNCS, even at low doses, would be therapeutically useful for the local treatment of rheumatoid arthritis.

Synovial Hemangioma Presenting as a Painful Locked Knee A Case Report

A 39-year-old man presented to orthopaedic care with a painful, fully locked knee. Workup revealed free intraarticular nodules, which were subsequently arthroscopically removed and identified to be synovial hemangioma. To the investigators' knowledge, this is the second reported case of synovial hemangioma presenting as a painful, definitively locked knee. Synovial hemangioma should be considered in the differential diagnosis of knee pain, particularly after more common diagnoses have been ruled out. Efficient and appropriate diagnosis and treatment may result in favorable patient outcomes and avoid long-term disability and dysfunction.

Extensor Tendon Impingement in a Gymnast

Wrist injuries in the gymnast are due to the transformation of the upper extremity into a weight bearing entity. Gymnast wrist pain presents a difficult diagnostic and therapeutic challenge. Here, we present a new case of extensor tendon impingement in an elite gymnast. To our knowledge, there is no similar report in the literature.

[Long-term outcomes of arthroscopy and non-surgical therapy in patients with knee synovial plica syndrome]

OBJECTIVE

To compare the long-term outcomes of arthroscopy and non-surgical therapy in patients with knee synovial plica syndrome (SPS).

METHODS

Thirty-one patients with knee SPS undergoing arthroscopic surgery and 27 SPS patients undergoing conservative treatment with articular cavity injection of sodium hyaluronate (control group) were compared for visual pain score (VAS) and the Lysholm score before and after the operation. The patients were followed-up for more than 5 years, and the long-term outcomes were compared using Kaplan-Meier survival analysis.

RESULTS

s VAS and the Lysholm scores in both groups were significantly lowered after treatment (P<0.05). The postoperative VAS score was significantly lower while the Lysholm score significantly higher in arthroscopic surgery group than in the control group (P<0.05). Arithmetic mean and the median time of curative effect maintenance were 49 and 43 months in arthroscopic surgery group, as compared with 33 and 29 months in the control group, respectively; the cumulative effect maintenance rate in arthroscopic surgery group was significantly higher than that in the control group (Χ2=4.933, P=4.933).

CONCLUSION

Arthroscopic treatment produces better therapeutic effect on knee joint SPS and ensures longer long-term therapeutic effect maintenance than conservative treatment.