Two cases of synovial haemangioma of the knee joint: Gd-enhanced image features on MRI and arthroscopic excision

Synovial haemangioma of the knee joint is a relatively rare benign condition with around 200 reported cases. We have recently encountered two cases of synovial haemangioma of the knee joint which preoperative MRI had assessed as highly suspect and which arthroscopic resection and subsequent histological examinations confirmed as synovial hemangiomas. Published studies have identified the following as characteristic MRI features of synovial haemangioma: homogenous low intensity to iso-intensity on T1 sequence; and heterogeneous high intensity with low-intensity septa or spots within the lesion on T2 sequence. However, several other intra-knee disorders mimic these characteristics. In our two cases, we found that gadolinium (Gd)-enhanced images, which have been relatively rarely discussed in the literature, were useful for making the diagnosis and for determining the extent of this condition. These images also were very helpful during arthroscopic excision of the lesion. Nonetheless, even after Gd enhancement, differentiating between malignant conditions such as synovial sarcoma and haemangioma solely from MRI findings is still difficult.

SYNOVIAL CHONDROMATOSIS OF THE DISTAL RADIOULNAR JOINT

Synovial chondromatosis is a rare lesion in the wrist and it is extremely uncommon in the distal radioulnar joint. This case presented with wrist pain, swelling and locking secondary to synovial chondromatosis of distal radioulnar joint.

Lipoma arborescens of knee joint: role of imaging

A 23 year old Asian female presented with swelling of right knee joint for 5 years with history of exacerbations and remissions of symptoms. She was initially diagnosed as a case of suprapatellar bursitis based on clinical and X-ray findings. Further evaluation with higher imaging modalities was pathognomonic of lipoma arborescens. Patient underwent synovectomy and the diagnosis was confirmed histologically. We describe a histologically proven case of lipoma arborescens to highlight the imaging findings on X-ray, Ultrasound and Magnetic resonance imaging with arthroscopic correlation. The unique feature of this case report is multimodality imaging correlation with arthroscopy and histopathology findings. We have highlighted the pathognomonic imaging findings of this rare but benign intra-articular lesion and also discussed the differential diagnosis in detail.

Micronucleus evaluation for determining the chromosomal breakages after radionuclide synovectomy in patients with hemophilia

OBJECTIVE

To investigate the genotoxic effects of (90)Y and (186)Re in patients with hemophilia who were undergoing radionuclide synovectomy (RS) procedure in the last 3 years.

METHODS

Nineteen patients were enrolled in the study. Most of the patients (n = 17) were hemophilia-A (mean age 20.6 ± 10.5 years) and 18 patients (mean age 22.6 ± 10.6 years) with hemophilia who were not exposed to RS procedure were included in the study as control group. Most cases in the control group (n = 13) were hemophilia-A. (90)Y for knee joints and (186)Re for elbow or ankle joints were used to perform RS in hemophilic patients. We studied the micronucleus (MN) test on peripheral blood lymphocytes as an indicator of radiation-induced cytogenetic damage and calculated nuclear division index.

RESULTS

There was no significant difference between the patients with and without RS with respect to MN values. However, both values obtained in RS-exposed patients and control group were much elevated than values reported in literature from healthy controls. The mean MN values of patients below 20 years old were much lower but not significant than those above 20 years old. MN frequencies between (186)Re and (90)Y groups were also analyzed, and no significant difference was observed. Hemophilia patients who were treated with (186)Re showed higher levels of MN compared to patients treated with (90)Y although the difference was not significant.

CONCLUSIONS

Radioisotope synovectomy (RS) seems to be a safe procedure not causing a significant genotoxic effect on hemophilic patients, however, further studies including larger series of patients are needed to better understand the effects of RS on patients' health.

[A 2-year follow-up results of knee arthroscopic synovectomy plus disease modifying antirheumatic drugs for the treatment of rheumatoid arthritis]

OBJECTIVE

To evaluate the clinical efficacy of knee arthroscopic synovectomy plus disease-modifying antirheumatic drug (DMARD) for the treatment of rheumatoid arthritis (RA) patients.

METHODS

A total of 97 RA patients were treated with knee arthroscopic synovectomy plus DMARD after arthroscopy. The control group received only DMARD. The patients were assessed at pre-treatment and 1, 6, 12, 24 month post-treatment. Tender joint count, swollen joint count, morning stiffness, resting pain, patient global assessment, physician global assessment, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF) and disease activity score (DAS) 28 were observed.

RESULTS

Tender joint count, swollen joint count, morning stiffness, resting pain, patient global assessment, physician global assessment and DAS 28 score improved significantly at 1, 6 month post-treatment in the combined treatment group versus the control group. At 2 years post-treatment, there was still significant difference in DAS28 between two groups.

CONCLUSION

The combined treatment of knee arthroscopic synovectomy and disease modifying antirheumatic drugs can control the disease activity of RA during an early period. And a long-term efficacy may be maintained.

Synovial chondromatosis of the shoulder: open synovectomy and insertion of osteoarticular allogaft with internal fixation to repair intraoperative glenohumeral joint instability

Synovial chondromatosis is a rare benign disorder characterized by chondroid metaplasia with multinodular proliferation of the synovial lining of a diarthroidal joint, bursa, or tendon sheath. These cartilaginous nodules may become embedded within the proliferating synovium and may extend into the surrounding soft tissues. They also can detach from the synovium, where they can calcify and may present as intra-articular loose bodies. Presence of these nodules leads to joint pain, dysfunction, and ultimately, destruction. Clinically, patients often present with a chronic monoarthropathy. In this article, we report a case of extensive synovial chondromatosis of the right shoulder and surrounding soft tissues with extensive erosion of the humeral head, discuss combined anterior and posterior surgical excision of the cartilaginous fragments, and describe insertion of an osteoarticular allograft to repair the humeral head defect and secondary anterior glenohumeral joint instability.

Preparation and pre-clinical study of 177Lu-labelled hydroxyapatite for application in radiation synovectomy of small joints

AIM

We present in this paper, the preparation and pre-clinical study of 177Lu-labelled hydroxyapatite for the application in radiation synovectomy of small sized joints.

METHODS

177Lu is an adequate radionuclide for therapy, having ability of simultaneously showing therapeutic effects and depicting images. Both hydroxyapatite particulates and 177Lu were prepared indigenously.

RESULTS AND CONCLUSION

Analysis of the gamma ray spectrum showed the radionuclide purity of 177Lu more than 99%. HA particles were synthesized and characterized by FTIR-ATR and X-ray diffractometry. XRD-Pattern generated by the product indicated that the chief inorganic phase of the sample is hydroxyapatite crystal. FTIR spectrum of HA powder calcined at 800°C for 1h showed all the bands that can be assigned to phosphate and hydroxyl groups in an apatite environment. Ca/P ratio was determined by ICP-OES. The Ca/P ratio of 1.68 determined for HA was about 0.6% above the stoichiometric ratio of 1.67. Particle size distribution pattern was obtained with the help of laser particle size analyzer and results showed that more than 80% of the particles bear the size in the range ideal for radiosynovectomy. 177Lu-labelled hydroxyapatite particulates were prepared with high radiochemical purity and yield. >95% labeling yield was achieved at pH 7. Labeled specie remained stable up to 18 days. In vitro stability >99% remained up to >one half life of 177Lu. Bio-evaluation of the 177Lu-HA particles was carried out by injecting approximate activities of 10 and 5 MBq (in 0.1 mL suspension) as intra-articular injection in the right knee joints of rabbit 1 and 2 respectively. Retention of activity was studied using images of the injected joints with the help of a gamma camera at various intervals. In all images no activity was visible in any organ other than knee joints. The retention of the 177Lu activity was followed for 772 hours (30.01 days). Leakage of activity was also assessed indirectly by estimating the residing time of radiopharmaceutical in the synovium. Half life of 177Lu-HA residing time in the knees was estimated to be 154 hours and 158 hours for rabbit-1 and rabbit-2 respectively. No significant extra articular leakage of the injected activity was observed over a period of one month post injection. Pre-clinical study of 177Lu-labelled hydroxyapatite indicated its potential for application in radiation synovectomy of small joints.

Patellar instability: combined treatment with Goldthwait technique and arthroscopic lateral release

Patellar instability is a frequent cause of knee pain in childhood and adolescence. Treatment is usually conservative especially after a single episode of dislocation, although in cases of recurrence the surgical option needs to be evaluated. The techniques proposed involve only soft tissues in order to preserve the skeletal maturation. This study evaluates the long-term results on 20 knees in 19 adolescents affected by patellar instability treated with the distal realignment procedure involving medial transfer of the lateral hemi-patellar tendon according to Goldthwait technique, preceded by arthroscopy to perform lateral release. The results were analysed with the Cox grading system and showed 11 excellent cases, 6 good cases, 2 fair cases and 1 poor case. Similar findings were obtained with the Bray score.

Rheumatoid synovectomy: does the surgical approach matter?

BACKGROUND

Surgical synovectomy relieves pain in patients with rheumatoid arthritis (RA). The comparative effect of arthroscopic versus open synovectomy on pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent total joint arthroplasty (TJA) is unclear. Whether synovectomy relieves pain in patients with advanced degenerative joint changes is also controversial.

QUESTIONS/PURPOSES

We therefore asked whether arthroscopic synovectomy resulted in equal pain relief, recurrence rates, rates of radiographic progression, likelihood of arthroplasty, and whether surgical synovectomy relieved pain and halted progression in the presence of advanced RA.

METHODS

We searched PubMed, Cochrane Database of Systematic Reviews, and BMJ Clinical Evidence. After appropriate selection criteria, 58 studies were identified, including 36 on open synovectomy and 22 on arthroscopic synovectomy, with a total of 2589 patients and a mean followup of 6.1 years. Meta-analysis was performed for knees and elbows, comparing open versus arthroscopic synovectomy. Variables included the percentage of patients with pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent TJA or arthrodesis.

RESULTS

Patients undergoing arthroscopic synovectomy had similar pain reduction, but more frequent recurrences of synovitis and radiographic progression than patients with open synovectomy. Patients undergoing arthroscopic synovectomy had similar and decreased risks of subsequent elbow and knee arthroplasties, respectively. Advanced preoperative radiographic RA did not correlate with worse pain scores nor increased need for subsequent arthroplasty when compared with minimal degenerative joint changes.

CONCLUSIONS

Arthroscopic synovectomy, while providing similar pain relief, may place patients at higher risk for recurrence and radiographic progression of RA. Advanced preoperative degenerative joint disease should not be an absolute contraindication to synovectomy.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Synovial chondromatosis and tuberculosis of the hip coexistence]

This article describes a rare case of primary synovial chondromatosis of the hip associated with active tuberculosis of the hip. Twenty four years old patient underwent total hip replacement at our institution. No reactivation of the infection was detected in the four-years follow-up. Clinical and radiological evaluation of our material showed that joint space widening may be the first sign in synovial chondromatosis of the hip. Importantly, if the tuberculosis infection is suspected we have to take the material for bacteriological investigation, regardless of others, obvious diagnosis.

Posttraumatic impingement syndrome of the ankle--indication and results of arthroscopic therapy

BACKGROUND

Persisting pain after an ankle sprain is often caused by the development of intraarticular fibrous scars or even tibiotalar spurs due to repetitive trauma. This may result in a posttraumatic impingement syndrome of the ankle. Pain is typically provoked by dorsiflexion of the ankle and palpation of the tibiotalar anterior joint space. The study evaluates the outcome of arthroscopic treatment of the ankle impingement syndrome.

METHODS

32 patients are included (16-65 years, mean age 38 years) who underwent an arthroscopic operation because of an impingement syndrome of the ankle grades I-III (Scranton) due to a trauma without therapeutic response to conservative therapy over 3 months. Diagnostic criteria were palpatoric anterior ankle joint pain and pain provoked by dorsiflexion, in cases of grades II and III lesions spurs on the X-ray as well. The mean follow-up time was 49 months. The evaluation of the results was done with the West Point Ankle Score. The study is designed as a retrospective case series.

RESULTS

26 patients reached more than 80 points in the West Point Ankle Score corresponding to a good or excellent result (mean result 86 points, ranging from 80 to 98 points). The preoperative mean score reached up to 64 points overall (57-70). Five patients rated the postoperative result fair, one bad with 73 points at mean (62-78). Preoperatively they reached 56 point on an average (48-62). The fair and the poor results were associated with severe ankle sprain leading to ligament ruptures or fractures where severe chondral lesions were to be found with arthroscopy.

CONCLUSIONS

The results of the study show that ankle arthroscopy with resection of hypertrophic synovium and fibrous bands (type I) or tibial spurs (types II and III injuries) after an ankle sprain haven proven to be a reliable therapy for a posttraumatic impingement syndrome of the ankle that does not respond to conservative treatment. It is characterized by low morbidity and good to excellent results in most cases. The outcome of arthroscopic treatment was related to the extent of chondral lesions.

Tenosynovial giant cell tumor of the thigh: positron emission tomography findings

Tenosynovial giant cell tumors (TGCTs) are pigmented villonodular proliferative lesions originating from the synovium, bursa, or joint. TGCTs tend to be locally aggressive, and there is a chance for multiple occurrences, which often lead to impairment of joint function. In this article, we report the case of a diffuse-type extra-articular TGCT found in the thigh of a 36-year-old woman. Surveillance F-18 fluorodeoxyglucose positron emission tomography detected increased activity within the left thigh. This activity was confirmed with magnetic resonance imaging and with surgical excision and histopathologic determination of the tumor. This patient's case suggests that TGCTs may be discovered and followed after resection with positron emission tomography.

[Large-joint synovectomy in the era of biological therapies]

Since the mid 1980s, a global decrease in surgical procedures related to rheumatoid arthritis (RA) has been documented for joint-preserving procedures such as synovectomy as well as joint replacement surgery. This reflects improvements in the early management of rheumatoid arthritis and availability of more effective medical treatment. The present review summarizes the recent literature on the frequency of orthopaedic surgery in RA patients as well as the role of synovectomy in the rheumatoid hip, knee and shoulder in times of biological RA therapy.

Hemophilic arthropathy of the elbow

Hemophilia is a hereditary disease in which circulating levels of coagulation factors are lacking, resulting in a propensity toward bleeding. Intra-articular hemorrhages are a hallmark of hemophilia and may lead a cascade of cytokine elaboration and inflammatory-mediated changes, which ultimately result in cartilage loss and arthropathy. Diarthrodial joints, such as the knee, elbow, and ankle, are most commonly affected. This article highlights issues surrounding hemophilic arthropathy of the elbow and focuses on preventive measures, management strategies of the hemophilic elbow, and treatment options for established arthropathy.

Radiosynovectomy in hemophilia: quantification of its effectiveness through the assessment of 10 articular parameters

BACKGROUND

Radiosynovectomy (RS) can reduce the number of hemarthroses in chronic hemophilic synovitis. The purpose of this study was to quantitatively assess the effectiveness of RS in terms of the objective improvement of ten articular parameters.

METHODS

One-hundred and fifty-six radiosynovectomies were performed in 104 joints of 78 hemophiliacs diagnosed with chronic synovitis. The mean patient age was 18 years. The RS was carried out with either yttrium-90 or rhenium-186 (1-3 injections with a 6-month interval between them).

RESULTS

RS resulted in significant improvement in nine of the 10 variables studied, namely in the number of episodes of hemarthrosis, articular pain, range of motion (ROM) in flexion. ROM in extension, muscle strength (MS) in flexion, MS in extension, the degree of synovitis detected on clinical examination, the size of the synovium as measured by means of imaging techniques (in millimeters), the clinical scale developed by the World Federation of Haemophilia (WFH), and the radiologic scale of the WFH. The tenth parameter, the WFH radiologic score, showed no improvement. The other nine parameters studied improved independently for each one of the intra-articular injections of the radioisotope.

CONCLUSIONS

Categorization of the variables with regard to the degree of improvement achieved showed that the number of episodes of hemarthrosis and the severity of pain were the variables associated with the greatest improvement, with a 70% decrease in the amount of bleeding and in the level of pain experienced by the patient. The reduction of articular bleeding after RS was 67.6% when RS-1 was used, 62.1% with RS-2 and 61.2% with RS-3. Synovial hypertrophy as assessed clinically and by imaging techniques also showed a reduction of 30% and 39%, respectively. The WFH clinical scale revealed an improvement of around 19%. MS also improved in flexion and extension (7.9% and 8.2% improvement, respectively). ROM showed a slight but non-significant improvement.

[Foot and ankle surgery]

Rheumatoid arthritis is a systemic disease that often affects the foot and ankle (85%-100% of patients). There are characteristic deformities in relation to the stage of disease. Clinical assessment of both lower limbs is important, since factors such as valgus deformity of the knee can cause malposition of the foot and ankle. In the early stages, patients present with joint effusion which causes destruction of the cartilage ("stiff type") and distends ligaments and capsules ("loose type"). Medial and lateral ankle tendons are destroyed and become insufficient. A reduction in walking distance, pain, instability and difficulties with footwear lead to reduced quality of life. The talonavicular joint and rheumatoid forefoot destruction are in most cases the central problem in the foot deformity. Adequate medical therapy of the rheumatic disease is mandatory. Conservative treatment such as orthotic shoe devices should be used in the early stages and are concomitantly used after surgical treatment. Rheumatoid arthritis is a systemic disease requiring careful, stage-specific perioperative management.

[Hand and wrist surgery]

Despite improved medical treatment of rheumatoid arthritis, carpal tunnel compression, caput ulnae syndrome and palmar and dorsal tenosynovitis with potential tendon rupture represent urgent surgical indications. While diagnostic and therapeutic synovectomy may guide medical treatment, it should be performed before joint instability and destructive arthritis are established. Swan-neck and Boutonniere deformities as well as ulnar or radial drift of metacarpophalangeal (MCP) joints or the wrist can only be corrected when the involved joints are supple and intact. In the presence of destructive arthritis, partial and total wrist fusion, arthroplasties of the MCP joints and arthrodeses of the distal interphalangeal joints are recommended.

Arthroscopic treatment of localized and diffuse pigmented villonodular synovitis of the knee

Pigmented villonodular synovitis (PVNS) is a rare proliferative synovial disorder of uncertain etiology. Two forms of this disorder, a localized (LPVNS) and diffuse (DPVNS) form, are well differentiated. The therapy of choice for LPVNS is arthroscopic partial synovectomy with excision of the lesion. Total synovectomy, whether done arthroscopically or through an open arthrotomy, is the recommended treatment for DPVNS. During an eight-year period 13 patients, six male and seven female, average age 28 years (range, 16 to 60 years) were treated for PVNS of the knee with arthroscopic synovectomy. Average follow-up was 84 months (range, 28 to 127 months). Four patients were affected by localized PVNS and were subjected to partial arthroscopic synovectomy (two to three portals) with a complete lesion excision. The remaining nine patients presented with the diffuse form of PVNS and all of them underwent total arthroscopic synovectomy (five portals). The diagnosis was confirmed by synovial biopsy. Each patient was evaluated before treatment and at final follow-up. Results were assessed clinically, radiographically and subjectively and were rated as excellent, good, fair, or poor. No complications or recurrences were noted in the LPVNS group, and all four patients were rated as excellent. In the DPVNS group, eight patients were rated as excellent and one patient was rated as fair and it was the patient who suffered the only recurrence in our case series. No relevant complications were encountered. No cases of infection, joint stiffness or neurovascular lesions were seen. Arthroscopy has become the golden standard in treatment of LPVNS, and can undoubtedly give results that are as good as with open synovectomy when treating DPVNS, if performed by an experienced arthroscopic surgeon.

Arthroscopic treatment of localized pigmented villonodular synovitis: long-term functional results

Pigmented villonodular synovitis (PVNS) is a proliferative disorder that may lead to joint destruction and activity limitation. We conducted a retrospective study to determine the long-term results of localized PVNS (LPVNS) treated with arthroscopic excision, specifically with respect to postoperative activity level and symptom resolution. We reviewed the cases of 11 patients who had been treated with arthroscopic excision and partial synovectomy of LPVNS and been followed up for a mean of 112 months. Preoperative and postoperative Ogilvie-Harris scores, Tegner activity level scores, and UCLA activity level scores were calculated to determine disease-specific and general functional outcomes, respectively. We noted 2 cases in which posteromedial lesions recurred, moderate resolution of preoperative symptoms in most cases, and 2 cases in which the patient developed secondary osteoarthritis requiring surgical intervention. Arthroscopic excision of LPVNS can improve symptoms with a return to preoperative activity levels, but patients may develop secondary osteoarthritis after treatment, as noted in long-term follow-up.

Arthroscopic synovectomy for the rheumatoid elbow

PURPOSE

To describe an arthroscopic technique for complete removal of the synovium from the elbow joint and to investigate the clinical outcomes of arthroscopic synovectomy in patients with rheumatoid elbow.

METHODS

Arthroscopic synovectomy was performed on 26 rheumatoid elbows in 25 patients with radiographic changes of Larsen grade 3 or less. We performed total synovectomy of the elbow using multiple portals and by dividing the elbow into the anterior, posterior, and radiocapitellar compartments. At a mean follow-up of 33.9 months (range, 13 to 68 months), pain was evaluated with a visual analog scale and range of motion was measured. The Mayo Elbow Performance Score was used to assess total elbow function. Radiologic changes were determined according to the Larsen grading system.

RESULTS

The mean visual analog scale score for pain decreased from 6.5 to 3.1, and the mean flexion arc increased from 98.1 degrees to 113.3 degrees after the operation. The mean Mayo Elbow Performance Score improved from 58.5 to 77.4 points. There were 2 excellent, 17 good, 4 fair, and 3 poor results. Radiologic assessment showed no change in 13 elbows, improvement in 6, and progression in 7. Clinically apparent synovitis recurred in 4 elbows, in which the result was considered unsuccessful.

CONCLUSIONS

Arthroscopic synovectomy of the elbow by use of multiple portals is a technically feasible procedure. It can effectively relieve pain, increase range of motion, improve Mayo Elbow Performance Score, and delay radiologic progression in rheumatoid elbows, resulting in a high satisfaction rate, although recurrent synovitis occurs in some patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Effects of synovial interposition on healing in a canine tendon explant culture model

PURPOSE

To investigate whether synovium interposition between repaired tendon ends can integrate into the tendon repair and improve tendon healing strength in a canine tendon explant culture model.

METHODS

We used 80 flexor digitorum profundus tendons from 10 mixed-breed dogs for this study. The flexor digitorum profundus tendons were assigned to 2 groups: repaired tendons with synovium implanted between the cut tendon ends and repaired tendons without any implantation between the tendon ends. The repaired tendons were cultured for either 2 or 4 weeks and then assessed mechanically for rupture strength and histology.

RESULTS

The strength of the repaired tendons with the synovium interposition was significantly higher (p < .001) than the repaired tendons without interposition at both 2 and 4 weeks. The strength of the repaired tendons at 4 weeks was significantly higher than that at 2 weeks in both groups.

CONCLUSIONS

Interpositional synovial grafts have the potential to accelerate tendon healing when they are implanted at the repair site. The exact mechanism of this effect remains to be elucidated.

Bilateral synovial chondromatosis of the temporomandibular joint

PURPOSE

To report an exceptional case of bilateral synovial chondromatosis (SC) of the temporomandibular joint (TMJ) and discuss diagnostic approaches, treatment options and follow-up data.

PATIENTS AND METHODS

A 38-year-old woman presented with left preauricular swelling. Initial imaging studies revealed TMJ effusion only. Six years later, synovial calcifications were detected in the left TMJ; the right TMJ space was widened and presented incipient calcium deposits. Open arthrotomy of the left TMJ was performed, with removal of multiple cartilaginous loose bodies and complete synovectomy. Periodic controls proved the asynchronic development of intra-articular bodies in the right TMJ.

RESULTS

SC is a metaplastic arthropathy that is uncommon in the TMJ. Bilaterality is exceptional. Diagnosis is often delayed due to the non-specific symptoms, progressive developmental stages and clinicians' lack of awareness of the condition. Magnetic resonance imaging (MRI) is particularly helpful in defining disease extension, excluding a possible tumour and detecting internal derangement. Definitive diagnosis requires arthroscopic or open examination and histopathological analysis. Recurrences are infrequent after arthrotomy, removal of loose bodies and complete synovectomy.

CONCLUSION

SC is an uncommon condition in the TMJ. Bilateral involvement is extremely rare. MRI is effective for diagnosis and postoperative follow-up. Complete synovectomy usually yields an excellent prognosis.

Rheumatoid forefoot reconstruction

Management of the patient with rheumatoid forefoot deformity requires a multidisciplinary integrated approach for a successful outcome. Despite recent advances in the pharmacological management of rheumatoid arthritis and its impact upon disease progression, forefoot deformity and pain remain common manifestations requiring input from orthopaedic surgeons. The typical deformities encountered include hallux valgus, with subluxation or frank dislocation at the lesser metatarsophalangeal (MTP) joints. Surgical intervention is directed at correcting and decompressing these deformities, with the ultimate goal of a stable, painless, functional plantigrade foot. Although a variety of surgical options exist, fusion of the 1st MTP joint with lesser MTP joint excision arthroplasty remains the gold standard, upon which newer procedures should be judged. This article reviews the pathophysiology of forefoot deformity in rheumatoid arthritis with special emphasis on recent advances in surgical management.

Revision total hip arthroplasty for ceramic head fracture: a long-term follow-up

The results of revision total hip arthroplasty (THA) for ceramic head fracture have generally been disappointing, largely due to third body wear after incomplete synovectomy. We have followed 8 patients who sustained ceramic head fractures and were subsequently revised to a metal-on-polyethylene articulation. There were no revisions for osteolysis or aseptic loosening at a mean follow-up of 10.5 years. The yearly wear rates of each of 5 of these THAs after revision were compared with 6 matched metal-on-polyethylene THAs; there were no significant differences in wear rates. Greater than 10-year survivorship with a metal-on-polyethylene bearing couple is possible after revision THA for a ceramic head fracture if a complete and thorough synovectomy can be performed. Our technique of synovectomy will be described.