Is radiation synovectomy for arthritis of the knee more effective than intraarticular treatment with glucocorticoids? Results of an eighteen-month, randomized, double-blind, placebo-controlled, crossover trial

OBJECTIVE

To compare the clinical efficacy and safety of radiation synovectomy (RSO) with intraarticular (IA) yttrium-90 plus glucocorticoids (GCs) with the efficacy and safety of IA placebo yttrium plus GCs and to identify parameters that predict efficacy.

METHODS

The knees of 97 patients with persistent arthritis despite outpatient treatment with IA GCs (n = 113 knees), were treated with either IA (90)Y plus GCs (50%) or IA placebo yttrium plus GCs (50%), followed by 3 days of bed rest in the hospital clinic, with splinting of the treated knee. Predominant diagnoses were undifferentiated arthritis (39%) and rheumatoid arthritis (32%). The clinical effect of therapy was assessed at 6 months using a composite change index (CCI; range 0-12). The primary outcome measure was the response rate (i.e., the percentage of joints with a CCI > or =6). Knees with persistent arthritis after 6 months underwent crossover therapy (51% of the (90)Y plus GCs group versus 45% of the placebo plus GCs group). Adverse effects and radiologic damage during followup were documented.

RESULTS

Neither the response rate (48% in both groups), the mean CCI, nor the duration of remission was significantly different between groups. No clinically relevant short-term adverse effects were observed, except for progression of radiologic damage in 34% of the (90)Y plus GCs group versus 28% of the placebo plus GCs group (knee prosthesis placement in 8% versus 1%). The functional and radiologic status at study entry predicted the clinical effect.

CONCLUSION

Treatment with (90)Y plus GCs with bed rest and splinting is not superior to IA GCs with bed rest and splinting. Over the short term, both treatments appeared to be safe, although a negative effect of (90)Y on cartilage and bone cannot be ruled out. Thus, it appears that RSO with (90)Y should no longer be considered the treatment of first choice for persistent arthritis of the knee.

Arthroscopic synovectomy in wrist arthritis

Arthroscopic synovectomy is a safe outpatient procedure with minimal postoperative morbidity. In patients who have rheumatoid arthritis and possibly also in patients who have JRA, SLE, and postinfectious arthritis, a long period of increased comfort and improved function can be anticipated. The procedure may be considered in post-traumatic cases with joint contracture and as an adjunct to other measures for certain osteoarthritic disorders. In patients who have septic arthritis with insufficient clinical improvement after systemic antibiotics and lavage, arthroscopic synovectomy seems advantageous.

Intraarticular synovial lipoma of the knee located in the intercondylar notch, between ACL and PCL: a case report and review of the literature

This report presents a 16 year old girl with persistent left knee pain caused by an intra-articular synovial lipoma (IASL) of the knee. Arthroscopy revealed a lipoma arising from the posterior aspect of the synovial membrane, extending in the femoral intercondylar notch, between the femoral attachments of anterior cruciate ligament and posterior cruciate ligament. Histological examination confirmed the diagnosis of IASL. IASL is a rarely described situation. There are only a few references in the literature. One IASL found in an adolescent and one more located in the intercondylar notch have been described.

Posterior cruciate ligament reconstruction using hamstring tendon graft with remnant augmentation

Despite good early functional results, the posterior laxity of the knee is not completely eliminated after posterior cruciate ligament (PCL) reconstruction. The PCL can retain the normal tension only when the injured ligament is maintained anatomically. This article describes a technique of PCL reconstruction using hamstring tendon graft with PCL remnant augmentation. The harvested hamstring tendons were quadrupled, sized, and pretensioned before use. The PCL remnants and the synovium were preserved. Minimal debridement was performed to gain access to the insertion sites. The tibia and femoral tunnels were created with graft size-matched reamers. The graft was transfixed at 70 degrees of knee flexion with a 15-lb anterior drawer force on the proximal tibia. This surgical technique has several advantages. The hamstring graft acts as an independent PCL reconstruction and maintains the PCL remnant tension. The PCL remnants and synovium may be beneficial to ligament healing and postoperative rehabilitation. The procedure is technically feasible and cosmetically acceptable. The selection of autograft precludes the risks of allograft and artificial ligament. The short-term results are encouraging, but long-term results are needed to confirm the value of this technique for PCL reconstruction.

Tendoscopic debridement for stage I posterior tibial tendon dysfunction

Our objective is to assess whether the tendoscopic synovectomy is effective to control the stage I posterior tibial tendon dysfunction. Our study is a retrospective one. The participants, six patients with stage I posterior tibial tendon dysfunction, were treated with tendoscopy with synovectomy for the past 3 years. The results show that this is a safe procedure and we could achieve similar effectiveness as the traditional open procedure. There was no complication found. None of our patients have progressed to stage II or above posterior tibial tendon dysfunction. In conclusion, tendoscopic debridement is a minimal invasive surgery. It is effective to control the stage I posterior tibial tendon dysfunction. In addition, it had the advantages of smaller scars, less wound pain and a short hospital stay.

Synovial haemangioma of the knee: a case report

Synovial haemangioma is a rare but important cause of knee symptoms, which, when undiagnosed, can lead to significant morbidity. Diagnosis is frequently difficult and delayed. We report on a case of synovial haemangioma, which demonstrates the difficulties inherent in diagnosis and the morbidity associated with diagnostic delay, in a young woman. Magnetic resonance imaging (MRI) is a useful tool for diagnosis, but detection on MRI can also be problematic, as shown by this case, demonstrating the need for greater awareness of this condition by both clinicians and radiologists. Arthroscopy is important in both the diagnosis and treatment of these lesions.

Lipoma arborescens of the knee

Lipoma arborescens (diffuse articular lipomatosis) is a rare, benign intra-articular lesion of unknown aetiology. It is characterised by villous proliferation of the synovium and diffuse replacement of the subsynovial tissue by mature fat cells. It forms part of the differential diagnosis for a slowly progressive chronically swollen knee. We present a very rare case of bilateral involvement of the knee and discuss the symptoms, diagnosis and treatment of this condition.

Treatment of persistent infection after anterior cruciate ligament surgery

Infection after anterior cruciate ligament reconstruction that persists despite debridement is a challenging problem with limited information available in the literature. Our purpose was to determine whether an aggressive protocol would be effective in treating these persistent infections. This is a retrospective review of five consecutive patients with persistent septic arthritis of the knee after anterior cruciate ligament reconstruction. All patients previously had one to three irrigation and debridement procedures that failed to control the infection. Our treatment protocol consists of arthrotomy, complete synovectomy, removal of any implants, graft removal, and curettage of the femoral and tibial tunnels. Cultures are obtained from many sources (joint fluid, synovial lining, graft, and bone) and antibiotic therapy is given for 6 weeks. At a median followup time of 20 months (range, 6-27 months) infection was controlled in all patients. Three of five infections (60%) were polymicrobial. In these cases, different organisms were cultured from multiple tissue samples. Tunnel osteomyelitis was present in three of five patients (60%). Persistent septic arthritis of the knee after anterior cruciate ligament reconstruction can be controlled with a protocol based on radical debridement. Polymicrobial infections may be present and multiple cultures from different sources are required to identify all pathogens.

Successful Treatment of Postvenereal Reactive Arthritis With Synovectomy and 3 Months’ Azithromycin

BACKGROUND

The effects of antibiotic therapy on the course of postvenereal reactive arthritis have not yet been elucidated.

OBJECTIVE

The objective of this study was to observe the clinical course and outcome of synovectomy and 3 months of azithromycin therapy in patients with reactive arthritis and previously diagnosed triggering bacteria.

METHODS

We performed an open, prospective study on 20 (14 male/6 female) patients with postvenereal reactive knee arthritis, aged 36.7 +/- 14.8 years, and with 16.5 +/- 20.4 months' duration of the disease. Detection of bacteria triggers was done by polymerase chain reaction, isolation and identification, and electron microscopy. Synovectomy was performed in all patients at entry into the study. Azithromycin was given at a dose of 500 mg per day for 5 days, and then 500 mg twice a week, during a 3-month period. Patients without remission were treated with combined antibiotic therapy using a macrolide, quinolone, and tetracycline for the next 4 months. Outcome evaluations of therapeutic efficacy and azithromycin safety were done after 1 and 3 months and 2 years of follow up.

RESULTS

Remission, defined by the absence of joint swelling and tenderness, and extraarticular signs, was reached after 3 months in 15 of 20 (75.0%) patients (P = 0.025). Of 5 patients with persistent knee arthritis, remission was achieved with combined antibiotic therapy in 4. Visual analog scale scores (P < 0.01), the number of patients (P = 0.002), and the number of samples (P = 0.01) with a positive finding of bacteria or their DNA were significantly lower after 3 months of therapy. During the azithromycin therapy, there were no significant adverse effects.

CONCLUSIONS

These patients with reactive arthritis did extremely well on the regimen described. In our study group, the number of patients and the number of samples with positive findings of bacteria or their DNA were lower after the antibiotic treatment combined with surgery, although not all bacteria were eradicated. Adverse effects of prolonged azithromycin administration were insignificant. This open treatment approach is recommended but does need a study with controls.

Site-specific intraoperative efficacy of arthroscopic knee joint synovectomy in rheumatoid arthritis

PURPOSE

To assess the intraoperative reduction of inflammatory infiltrates achieved by arthroscopic knee joint synovectomy in patients with rheumatoid arthritis (RA) with special regard to the removal site, using preoperative and postoperative synovial tissue (ST) samples.

TYPE OF STUDY

A histologic and immunohistochemical study.

METHODS

Eleven patients with treatment-refractory RA knee synovitis underwent arthroscopic synovectomy. In each patient, ST specimens were obtained immediately before and after synovectomy from 9 defined sites covering the whole joint. The samples were graded using an acute synovitis score (ASS; presence of polymorphonuclear neutrophilic leukocytes [PMN] and fibrin) and a chronic synovitis score (CSS; e.g., lining cell hyperplasia, presence of diffuse and lymphoid aggregates). Immunohistologic analyses were performed using 7 monoclonal antibodies directed against PMN, macrophages, and T-cell subsets (total of 1,584 preparations). Knee function was assessed after an average follow-up of 28 months by Lysholm score (modified by Klein and Jensen), Insall functional and knee scores, and Lequesne score.

RESULTS

Arthroscopic synovectomy led to an overall significant (P between .005 and .05) reduction of the acute inflammatory infiltrates (ASS) by 82.1%, but to a significant reduction of chronic inflammatory infiltrates (CSS) by only 62.5%. Accordingly, the density of PMN was reduced by 81.8%, whereas that of macrophages and different T-cell subsets was only decreased by < or = 61.6%. With respect to the anatomic regions, a significantly (P < or = .05) less marked reduction of inflammatory infiltrates was observed in the upper lateral and central recess, at the medial and lateral capsule, as well as at the femoral insertion of the anterior cruciate ligament. All knee joint scores showed a significant (P < or = .01) improvement over preoperative values at follow-up.

CONCLUSIONS

Arthroscopic synovectomy effectively reduces acute and chronic inflammatory infiltrates in patients with RA who have refractory synovitis of the knee joint (immediately after synovectomy) and improves knee function (28-month follow-up). However, the reduction of inflammatory infiltrates appears to depend on the anatomic region of the joint.

LEVEL OF EVIDENCE

Level III.

Primary synovial chondromatosis of the shoulder: clinical, arthroscopic and histopathological aspects

Primary synovial chondromatosis is an uncommon condition, and involvement of the glenohumeral joint is rare. Currently, the recommended treatment is arthroscope-assisted synovectomy and removal of the loose bodies. We report a case with the clinical findings, radiographic features, arthroscopic technique for treatment of this disease and the main histological appearance of the removed loose bodies. We believe this is an easy and safe method for management of this disorder and that the support of an experienced pathologist is necessary to avoid differential diagnostic problems with the uncommon malignant transformation.

Outcome of surgical concepts in haemophilic arthropathy of the hindfoot

The ankle is one of the most frequent joint affected by haemophilia, in the second decade of life it can be considered as the most common site for haemophilic arthropathy. The aim of this study is to evaluate the results of 15 surgical interventions of the hindfoot performed on 11 patients. Twenty-seven of 70 male patients suffering from haemophilia were treated for haemophilic arthropathy of the hindfoot. We performed 15 operations on 11 patients with a mean age of 33.5 (range: 10-53) years. The surgical treatment consisted of 15 operations, 12 of which concerned the talocrural joint (six synovectomies, three radiosynoviorthesis, four arthrodeses, one achilles tendon lengthening) and one the talocalcaneonavicular joint (one triplearthrodesis). The arthrodeses of the talocrural joint were undertaken by screw, the triplearthrodesis by clamp fixation. The synovectomies were all late synovectomies and performed by open means. The mean follow-up period was 32.0 (range: 12-84) months. The mean age at surgery was 29.6 (range: 8-51) years. No perioperative complications were registered when adequate replacement therapy was carried out. The consolidation of the arthrodeses was accomplished within 8-12 weeks. All synovectomies stopped or reduced significantly recurrent joint bleeding. With both procedures we achieved pain relief and walking ability improvement. The aim of synovectomy is to reduce bleeding episodes. If synovectomy can halt the progression of the haemophilic arthropathy is controversially discussed, especially when surgery was carried out in the presence of an established arthropathy. If synovectomy fails, the arthrodesis proves to be a good treatment option.

Retinacular band excision improves outcome in treatment of plica syndrome

Mild symptoms usually continue after excision of the medial patellar plica. We noticed that the palpable tender cord, located on the anteromedial aspect of the knee in patients with plica syndrome, did not disappear completely after excision of the synovial fold. Beneath all plicae, a retinacular band was visible, and only after excisions of this band did the cord become impalpable. We conducted a study to determine the role of these medial retinacular bands in the symptomatology of the disorder. Twenty-four knees of 22 patients diagnosed with medial patellar plica syndrome were divided into two groups. In the first group, arthroscopic excision of the synovial plica was performed. In the second group, retinacular bands beneath the plica were additionally excised. When Lysholm scores were compared, we found that the second group showed significantly greater improvement. We believe that the retinacular bands play a role in the symptomatology and the pathophysiology of plica syndrome and that excision improves the outcome.

Arthroscopic synovectomy in haemophilic arthropathy of the knee

From January 1996 to January 2001, arthroscopic synovectomies were performed in 28 knees with haemophilic arthropathy. The mean follow-up period was 5 years and 11 months. Six portals (two anterior, two suprapatellar, two posterior) and a posterior trans-septal portal were used in all cases. The average Hospital for Special Surgery (HSS) knee score increased from 56.4 to 71.5 points at the last follow-up. The average frequency of haemarthrosis reduced from five times per month before operation to once per month. The amount of factor replacement decreased from a mean of 4,633 U to 1,505 U. Progression of arthritis was observed radiographically in three cases at the last follow-up. An arthroscopic synovectomy of the knee using appropriate arthroscopic portals is a useful method in treating haemophilic patients as it decreases bleeding episodes, amount of factor replacement and knee pain.

Long-term follow-up study of radiocarpal arthrodesis for the rheumatoid wrist

PURPOSE

Pain-free stability of the wrist is a prerequisite for the rheumatoid hand to maintain power and perform various tasks. The purpose of this study was to investigate whether a radiocarpal (radiolunate, radioscapholunate, or radiolunotriquetral) arthrodesis produces a stable wrist and whether the results remain satisfactory for more than 10 years.

METHODS

A retrospective review was performed on 25 wrists of 25 patients with rheumatoid arthritis who had radiocarpal arthrodesis. All patients had a synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. The indications for radiocarpal arthrodesis included radiographic changes in Larsen-Dale-Eek grades II to IV, midcarpal joint space of greater than 1 mm, and ulnar shift or palmar subluxation of the carpus. The presence of scapholunate dissociation was an optional indication. The mean follow-up period was 13 years (range, 10-18 y) and radiographs taken just before the surgery and 0 to 2 years, 2 to 5 years, 5 to 10 years, and more than 10 years after the surgery were evaluated as were pain relief, swelling, grip power, range of motion, and complications.

RESULTS

Pain was resolved for 22 of the patients and 3 experienced occasional mild pain. Swelling generally decreased, grip power increased significantly, flexion decreased, and forearm rotation increased significantly. The complication rate was low. Radiographically ulnar shift and palmar subluxation improved initially and were maintained at the time of the 10-year follow-up evaluation; carpal collapse improved initially but returned to the preoperative level by the time of the 5-year follow-up evaluation. The midcarpal joint space was preserved in 16 wrists, and all but 1 wrist (in a patient with mutilating type of the disease) remained stable.

CONCLUSIONS

Radiocarpal arthrodesis for treatment of the rheumatoid wrist results in good stability with preservation of motion despite radiographic progression of the disease. We therefore recommend this treatment for the unstable wrist with moderate deterioration.

Synovial Membrane Microarthroscopy of the Equine Midcarpal Joint

OBJECTIVE

To evaluate the value of microarthroscopy in the equine midcarpal joint using the vital stains methylene blue, trypan blue, neutral red, and Janus green B to observe components of the synovial lamina propria, vascular architecture, and synoviocytes.

STUDY DESIGN

Experimental.

ANIMALS

Ten horses.

METHODS

Microarthroscopy of left and right midcarpal joints was performed with and without vital staining of the synovium. Four vital stains (methylene blue, trypan blue, neutral red, and Janus green B) were evaluated, with each stain used in 5 joints. Synovial biopsy specimens were collected from the dorsomedial and dorsolateral aspects of the joint.

RESULTS

All dyes were biocompatible. At x 60 without vital staining, synovial surface topography, vascular network, and translucency were observed. Intra-articular vital dyes improved evaluation of synovial surface topography. At x 150 with vital staining, individual synoviocytes were clearly identified with all dyes, except neutral red. Although methylene blue provided the best in vivo microscopic differentiation of the structure of the intima, trypan blue had superior retention in conventionally processed synovial biopsies.

CONCLUSIONS

Methylene blue, trypan blue, neutral red, and Janus green B stains can be used safely for microarthroscopy. Good visualization of cells and vascular network can be obtained by microarthroscopy, and microarthroscopic evaluation of the synovium compares favorably with conventional histologic evaluation of biopsy specimens.

CLINICAL RELEVANCE

Microarthroscopy may be beneficial in both research and clinical diagnosis of equine articular diseases.

Bucket-handle tear of medial plica

Plicae are synovial folds, classified according to their anatomical relationship to the patella. The medial patellar plica is normally asymptomatic, but it may cause symptoms when it becomes thickened and fibrotic. We describe three cases of bucket-handle tear of the medial patellar plica. They all suffered from anterior knee pain and clicking. Our cases' symptoms began when they incurred twisting injuries to the knee; therefore, we think that they had an asymptomatic plica first. Pain and clicking began because of the bucket-handle portion rubbed over the medial femoral condyle with knee flexion, and they improved after resection of the bucket-handle portion. Consequently, we think that medial patellar plica can be symptomatic not only when it becomes thickened or fibrotic but also when a bucket handle tear occurs.

Surgical treatment of pigmented villonodular synovitis of the hip

BACKGROUND

Pigmented villonodular synovitis of the hip is a rare disease. Synovectomy is generally accepted as the only surgical treatment for the disorder, but there have been few studies with a sufficient sample size and duration of follow-up to allow the evaluation of long-term outcomes. The aim of this study was to determine the long-term outcome of the treatment in sixteen patients.

METHODS

Sixteen patients (nine men and seven women), with a mean age of 35.5 years at the time of surgery, were treated between 1970 and 1996. Complete synovectomy was performed in all patients; in addition, three had a cup arthroplasty, four had a total hip arthroplasty, and one had a monopolar arthroplasty. Clinical and radiographic outcomes were evaluated retrospectively at a mean of 16.7 years postoperatively. Only one patient was followed for less than eight years.

RESULTS

Nine patients needed repeat surgery, but only one had recurrent synovitis, as detected with pathological examination fourteen years after treatment with synovectomy and cup arthroplasty. Secondary osteoarthritis developed in all eight patients who had been treated with synovectomy alone, and four of them required a total hip arthroplasty within the follow-up period.

CONCLUSIONS

These results support earlier data indicating that osteoarthritis consistently develops in patients with pigmented villonodular synovitis of the hip. Complete synovectomy seems to be effective in preventing recurrence of the synovitis, but it does not appear to prevent the development of secondary osteoarthritis.

Chronically inflamed synovium from spondyloarthropathy and rheumatoid arthritis investigated by protein expression profiling followed by tandem mass spectrometry

We investigated the cytosolic proteome of inflamed synovial tissue by hierarchical clustering analysis and validated the feasibility of this proteome analysis by identifying proteins that were differentially expressed between rheumatoid arthritis (RA), spondyloarthropathy (SpA), and osteoarthritis (OA). Synovial biopsy samples were obtained from 18 patients undergoing needle arthroscopy for knee synovitis associated with RA (n = 6) and SpA (n = 6), and for joint effusion of the knee associated with OA (n = 6). Cytosolic proteins were extracted from the tissue and subjected to two-dimensional gel electrophoresis. Protein expression patterns were statistically analyzed and used for hierarchical cluster analysis. Proteins of interest were independently identified by matrix-assisted laser desorption/ionization- and electrospray ionization-mass spectrometry. Hierarchical cluster analysis of the complete match set, containing 640 spots, remarkably segregated SpA from RA and OA. Next, we used a subset of spots that was statistically, differentially expressed (P < 0.01), between RA and SpA, SpA and OA, or RA and OA, in both Student's t-test and Mann-Whitney U-test. The dendrograms revealed distinct clustering of RA versus SpA and RA versus OA. Spots that were differentially expressed between the groups were identified by tandem mass spectrometry. Fructose bisphosphate aldolase A and alpha-enolase showed higher expression levels in SpA than in OA (P < 0.01). Calgranulin A myeloid related protein-8 (MRP-8) was markedly up-regulated in RA and SpA patients in comparison to OA patients where this spot was below detection limit. The analysis of the cytosolic proteome of synovial tissue is a useful approach to identify disease-associated proteins in chronic inflammatory arthritis.

Debridement and continuous irrigation for the treatment of pyogenic arthritis caused by the use of intra-articular injection in the osteoarthritic knee: indications and outcomes

PURPOSE

To discuss the indications and therapeutic outcomes of synovectomy, debridement, and continuous irrigation for the treatment of pyogenic arthritis caused by intra-articular injection used in the treatment of osteoarthritis of the knee.

METHODS

Records of 41 patients with infectious arthritis of the knee who presented to our hospital from 1981 were reviewed. 11 of them had a history of intra-articular injection. They underwent synovectomy, debridement, and continuous irrigation using a Salem double-lumen tube after confirmation that one side of the femorotibial joint cartilage was basically healthy.

RESULTS

The infection was successfully treated in 9 of the 11 patients. Of these 9 patients, one died after 3 years and 2 underwent total knee arthroplasty after 3 and 8 years. The remaining 6 patients were followed up for 5 to 15 years. Five of them had deteriorating arthropathy, and the condition was unchanged in the others. Two of these 6 patients had pain while walking, and their Japanese Orthopaedic Association scores were 70. The remaining 4 had good knee function and reduction of pain, with a mean Japanese Orthopaedic Association score of 91 and a mean range of motion of 131 degrees.

CONCLUSION

Arthrodesis is frequently considered the treatment for osteoarthritis if the joint destruction has affected the weight-bearing surface. However, in our experience, even when inflammatory granulation develops in the cartilage surface of one side of the femorotibial joint, good results can still be obtained by synovectomy, debridement, and continuous irrigation. After the pyogenic arthritis has subsided, if osteoarthritis has advanced and bowleg has exacerbated, further treatment options are available, such as tibial resection and even joint replacement. Continuous irrigation should be considered a feasible treatment option for pyogenic arthritis.

Hand surgery in rheumatoid arthritis: state of the art and suggestions for research

OBJECTIVE

The role of surgery in the clinical management of patients with rheumatoid arthritis (RA)-associated hand dysfunction is still a subject of controversy. The efficacy of surgery in RA-associated hand dysfunction is assessed through an exhaustive review of published studies.

METHODS

A high-sensitivity search strategy was used to identify in MedLine and CENTRAL original studies related to hand and wrist surgery in RA patients. We selected articles including at least two adult RA patients which evaluated clinical outcomes through an observational or experimental design. Eligible studies were evaluated by standardized criteria. Two investigators independently used a pre-defined form to extract data about patient population, intervention, follow-up and clinical outcomes. Disagreements were discussed and resolved.

RESULTS

One hundred and ninety-six papers met inclusion criteria. Only five were randomized trials, while most studies followed an observational design, often of poor quality. As such, we could not pool data for statistical analysis; however, we were still able to provide a best evidence synthesis. A positive trend suggesting the efficacy of total carpal arthrodesis and metacarpophalangeal arthroplasty in reducing pain and improving function seemed to emerge from the published studies.

CONCLUSIONS

Despite recent advances in medical treatment, surgery still plays a role in the clinical management of RA-associated hand dysfunction. However, the majority of the available studies showed methodological flaws that prevented a clear definition of both surgical indications and criteria for choosing any specific procedure. Suggestions for further investigations are also provided.

[Synovialectomy of the metacarpophalangeal joints with reconstruction of the radial collateral ligaments -- long-term results in patients suffering from rheumatoid arthritis]

Rheumatoid arthritis may lead to destruction of MP joints and severe alteration of grip and other hand functions. Due to the improvement in medical treatment, synovialectomy of the MP joints is necessary only in late stages. Most centres prefer alloarthroplasties in late stages, as erosion of the cartilage and loosening of the ligaments have already led to destruction of the MP joints and destabilization of grip functions. We do not use alloarthroplasties as our first choice, but pay special attention to the reconstruction of the radial collateral ligaments. Therefore, the elongated radial ligaments are detached near their origin after synovialectomy of the dorsal aspects of the MP joint. After detachment of the radial ligament, the palmar aspects can be cleaned easily. The radial collateral ligaments are shortened and reinserted dorsally to gain slight supination. This study shows the long-term results of our patients. In a period of ten years, 74 patients (87 hands, 347 MP joints) were reexamined after an average of 55 months postoperatively. The loss of active motion was 18 degrees and ulnar deviation could be reduced from 25 degrees to 7 degrees. 71 % of the joints showed stable ligaments, 14 % loose, 15 % unstable ligaments. We saw recurrence of synovialitis in 18 % (10 % mild, 7 % significant, 1 % severe). Radiographs showed amelioration in 14 % of cases and deterioration in 39 %. There was no correlation between active range of motion, synovialitis and X-rays. Results were constant when compared with exams before and five years after surgery. Our investigation shows good and stable results, which can be easily compared with the outcome of other studies after alloarthroplasty. The main advantage in our procedure is the easy access to all parts of the MP joint, which allows complete synovialectomy. By shortening and reinserting the elongated radial collateral ligament, we achieve a mild supination and amelioration of grip strength. The results are constant in long terms. In case of recurrent synovialitis or loosening of the ligaments any other type of auto- and alloarthroplasties can still be performed.

The use of activated recombinant coagulation factor VII during haemarthroses and synovectomy in a patient with congenital severe factor V deficiency

Factor V deficiency is a rare hereditary bleeding disorder. Currently, FV concentrates are not available, and the treatment of spontaneous bleeding or bleeding associated with invasive procedures is transfusion of fresh frozen plasma (FFP). However, FFP transfusion can lead to the development of inhibitor to FV, and is associated with several potential transfusion reactions including allergic reactions. We report a patient with congenital severe FV deficiency with repeated haemarthroses of a shoulder joint, and progressively severe allergic reactions to FFP transfusions. In addition, the patient also developed acute pulmonary oedema. Activated recombinant coagulation factor VII (rFVIIa) was used as an alternative haemostatic agent to FFP. We describe the use of rFVIIa in this patient during haemarthroses, synovectomy, and physiotherapy.

Anatomy, biomechanics, and surgical approach to synovial folds within the joints of the foot

The presence of synovial folds in various joints of the foot has been previously documented. The function and clinical significance of these structures within the joint have not been established. Histologically they are considered anatomically different from a meniscus primarily owing to their makeup of loose connective tissue with nerve fibrils and several synovial cell layers. We hypothesize that the function of these folds is similar to that of the menisci: to increase joint congruity and stability. We further hypothesize that these folds will be present in joints of the foot that require greater stability. To demonstrate this, 41 fixated cadaveric feet were sectioned in the sagittal plane and the incidence and locations of the synovial folds were documented. Three fixated cadaveric feet were evaluated using a materials testing machine. The first metatarsophalangeal joint was incised, and the presence of the synovial fold was documented. The joint was then taken through its range of motion with and without the synovial fold while data on the force and displacement were collected. The steps were then repeated for the ankle joint. The results showed statistically stiffer ankle and first metatarsophalangeal joints with the synovial fold present, as determined by the stress-strain curve. On the basis of the presence and location of these synovial folds, we demonstrated arthroscopic surgical approaches to many of the documented joints that contain these folds. Because the folds contain synovial cells and vascular tissue, damage to them can result in considerable pain. In such cases, arthroscopic surgery would be of benefit. Further research may indicate whether they need to be salvaged during joint procedures to facilitate normal joint function or should be removed to reduce postoperative complications.

Arthroskopische Operationen

Die arthroskopische Chirurgie besitzt heute innerhalb der Gelenkchirurgie einen nicht mehr wegzudenkenden Stellenwert. Fast alle Gelenke sind der arthroskopischen Methode zugängig. Diese spezifische Chirurgie benötigt eine spezielle Fähigkeit und Fertigkeit des Operateurs, die eigens erworben werden muss. Die arthroskopische Chirurgie hat aber eine evidente Abhängigkeit von der Technologie und erfordert demzufolge eine gut funktionierende Infrastruktur und Kenntnis. Der große Vorteil der arthroskopischen Chirurgie liegt in der minimal invasiven Technik, welche die primäre postoperative Morbidität wesentlich verringert und dadurch bei adäquater und differenzierter Indikationsstellung entscheidende Vorteile für den Patienten sowie einen guten Aufwand/Nutzeneffekt aufweist.

Elbow tuberculosis: an unusual location and diagnostic problem

Tuberculous arthritis of the elbow joint is not commonly seen by orthopaedic physicians. In the past 20 years, with the pandemic of the human immunodeficiency virus and the increase in immunocompromised people, we have observed a resurgence of tuberculosis. Osteoarticular involvement has increased, too. Spinal and monoarthritis of weight-bearing joints such as the hip or knee are most frequently involved. The elbow joint is an uncommon location of osteoarticular tuberculosis. The aim of this case report is to describe a case of tuberculous arthritis of the elbow and the diagnostic problems that may arise and lead to a delay in treatment.

Synovectomy, debridement, and continuous irrigation for infected total knee arthroplasty

Since 1990, a total of ten joints in nine patients with infected total knee arthroplasty have been treated in our department within 21 days of the onset of infection. Their radiographs showed no evidence of implant loosening or "moth-eaten" appearance. They underwent synovectomy, debridement, and continuous irrigation without implant removal. Continuous irrigation was maintained for 7-29 days. It was possible to retain implants in eight joints of seven patients. Two joints of two patients were removed. Pain disappeared in all eight joints in which the implants were retained. Four patients could walk with one cane; one patient could walk with one crutch. Range of motion in five joints remained over 100 degrees. We recommend synovectomy, debridement, and continuous irrigation to cure an early stage infection of total knee arthroplasty.

Total elbow arthroplasty after previous resection of the radial head and synovectomy

We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total elbow arthroplasty in patients with rheumatoid arthritis. Fifteen elbows with a history of resection and synovectomy were compared with a control group of patients who had elbow arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 elbows and good results in two. The control group had excellent results in seven and good results in six. Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent arthroplasty of the elbow. However, there was a higher rate of complication in the study group compared with the control group.

[Management of affected flexor tendons in rheumatoid arthritis of the hand]

The affection to the flexor tendons of the patient with rheumatoid arthritis represents a substantial rheumatic change in the hand, which is characterized by restriction of movement, ulnar deviation in the level of the metacarpophalangeal joint and palmar incomplete dislocation. Early treatment by removing any possible constriction areas in synovial proliferations in the area of the flexor pullies or a complete tendosynovectomy makes an extensive restitution possible. In the case of only one ruptured flexor tendon, it can be treated by the transfer of the neighboring superficialis tendon or a tendon transplant. If there are multiple ruptures, the results will be clearly worse in regard to movement and strength, whereby as a rule the result is seriously influenced by articular destruction. Therefore, an early tendosynovectomy and a preventive operation to the wrist have to be recommended.

[Swan-neck and buttonhole deformities on rheumatic long fingers]

Patients suffering from rheumatoid arthritis in many cases develop typical swan-neck and buttonhole deformities. In the further course of the disease we observe several stages. In the beginning active and later passive correction are still possible, while ultimately a fixed contracture is present. The activities of daily life may be severely reduced. The pathology of the swan-neck deformity is initiated at the level of the metacarpophalangeal joint, while at the origin of the buttonhole deformity the synovitis of the proximal interphalangeal joint is obvious. In the early stages, synovectomy and balancing of the soft tissues are surgically indicated. In advanced stages, complicated soft tissue reconstruction in combination with alloarthroplasty or arthrodeses may become necessary to allow for sufficient finger function.

The rusty knee--pigmented villonodular synovitis

Pigmented villonodular synovitis (PVNS) is a distinct but rare clinical entity often presents late with a diagnostic difficulty. Its non-specific manifestations require exclusion of several chronic inflammatory disorders and other humorous lesions but all investigations including highly predictive magnetic resonance imaging (MRI) and arthroscopic examination are non-diagnostic demanding confirmatory tissue biopsy. A typical case of such lesion is presented to highlight some potential difficulties.

Pigmented villonodular synovitis of the foot and ankle

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare disease of uncertain etiology usually affecting the synovium of weightbearing joints.

METHODS

We retrospectively evaluated 11 patients who were diagnosed and treated for PVNS of the ankle and foot over a 13-year period with a minimum of 2-year followup. Four patients with ankle joint PVNS and one patient with PVNS of the fifth metatarsophalangeal joint were seen initially at our institution and were treated with surgery alone. Six patients with ankle joint PVNS were referred to our institution for recurrent PVNS lesions; two of these patients were treated with excision alone, and the other four patients had surgical excision followed by radiation therapy with dosages ranging from 3600-4000 cGy.

RESULTS

No recurrence was noted at a mean followup of 9 years for primary lesions and 3.5 years for recurrent lesions.

CONCLUSION

Based on these results, surgical excision of primary lesions and excision with postoperative radiation for recurrent lesions are recommended.

Arthroscopic synovectomy for the rheumatoid elbow: a short-term outcome

We evaluated the results of arthroscopic synovectomy of 11 rheumatoid elbows in 10 patients. All patients had severe pain and swelling, resulting from chronic synovitis, that had not responded to conservative treatment. We divided the patients into two groups according to preoperative Larsen grade: group A, grade 1, 2, or 3 (n = 6); and group B, grade 4 (n = 5). The visual analog scale and the Elbow Evaluation Sheet of the Japanese Orthopaedic Association were used for preoperative and postoperative evaluation of pain and function. Arthroscopy was performed by use of the procedure of Poehling et al, without resection of the radial head. The mean follow-up period was 37 months. Visual analog scale and Japanese Orthopaedic Association scores improved significantly in both groups, with relief of pain and satisfactory functional results. We recommend this procedure for patients with a persistently painful, swollen elbow with Larsen grade 1 to 4 due to rheumatoid arthritis.

Pigmented villonodular synovitis about the ankle: a review of the literature and presentation in 10 athletic patients

BACKGROUND

Pigmented villonodular synovitis (PVNS) is relatively uncommon. The disorder results in increased proliferation of synovium causing villous or nodular changes of synovial-lined joints, bursae and tendon sheaths. This study examines the occurrence of PVNS about the ankle and its association with trauma.

METHODS

Ten patients over a 10-year period were identified as having PVNS of the ankle. The average age was 40.2 (range 27 to 62) years. There were four women and six men. Average followup was 4.5 (range 1 to 11) years from the initial surgery. Four patients had bone involvement. All patients who were athletically active before symptoms arose complained of persistent pain and swelling in the lateral ankle. Their initial clinical symptoms were indistinguishable from commonly associated pathologies with persistent lateral ankle pain (i.e. tenosynovitis, osteochondral defects, os trigonum injury, and tendon tears). All patients had magnetic resonance imaging (MRI) revealing PVNS, which is represented by low-signal appearing masses on T1- and T2-weighted images. All patients' histopathology results revealed multinucleated giant cells and foam cells laden with hemosiderin deposits. All patients had synovectomy and tenosynovectomy.

RESULTS

Eight patients were able to return to some sports (range 4 to 12 months); two had continued pain, disability, and inability to return to sports because of recurrence.

CONCLUSIONS

PVNS should be considered in athletically active patients with persistent lateral ankle pain and swelling, particularly if bone erosions are visible on plain radiographs.

Arthroscopic synovectomy for hemophilic joint disease in a pediatric population

Children with hemophilia can develop progressive arthropathy. Arthroscopic synovectomy has been used to reduce hemarthroses, but few long-term results have been published. In this article the authors review their first 12 years of experience. Data are reported on 44 pediatric patients (69 joints: 39 ankles, 21 elbows, 7 knees, 2 shoulders). The median age at surgery was 10 years Median follow-up was 79 months. Joints with sufficient follow-up data showed a median bleeding frequency decline of 84% (P < 0.001). Median arc of motion was stable or improved in the year after surgery in ankles, elbows, and shoulders. Complications were rare. Radiographic scores worsened slightly. In this largest analysis of arthroscopic synovectomy for children with hemophilia, rehabilitation was not problematic.

The target joint

Bleeding into the joints is the most common manifestation of severe haemophiliacs. Although it may resolve spontaneously or with treatment, some patients find that one particular joint has recurrent bleeding; this is termed a target joint. Recurrent bleeding prevents the joint from regaining its range of motion, muscle strength and normal appearance. These changes become permanent, leading eventually to osteoarthritis. A target joint requires urgent and comprehensive treatment, especially in young patients, if permanent damage is to be prevented. Treatment with factor concentrate prophylaxis and physiotherapy can help to prevent new bleeds and allow the synovitis to resolve, but for persistent synovitis, synovectomy is recommended. The target ankle joint is a special challenge as it often develops in very young children when the articular cartilage is susceptible and compliance with conservative treatment is difficult.

Successful use of ReFacto continuous infusion in two paediatric patients with severe haemophilia A undergoing orthopaedic surgery

In this report we describe the successful use of B-domain-deleted recombinant factor VIII (ReFacto) administered by continuous infusion during orthopaedic procedures in two children with severe haemophilia A. Both patients underwent ankle synovectomy and in patient 2, a medial patello-femoral ligament repair was performed in the same operative session. Patient 2 developed septic arthritis A in his knee joint and arthroscopic joint irrigation and debridement was performed 2 weeks after the initial procedure. Surgical cover was initiated with a bolus dose of ReFacto 50 IU kg(-1) followed by continuous infusion at 3.3-4.8 IU kg(-1) h(-1) which was maintained for up to 9 days postoperatively. Patient 2 received an additional bolus dose of 15 IU kg(-1) during the infusion period. All procedures were performed without haemostatic complications and long-term orthopaedic outcomes were good in both patients.

Influence of previous open synovectomy on the outcome of Souter-Strathclyde total elbow prosthesis

OBJECTIVES

Open synovectomy of the elbow joint is often performed in early stages of rheumatoid arthritis. Because of poor long-term results after synovectomy, insertion of a total elbow prosthesis is commonly used as a secondary procedure. The aim of this study is to evaluate the influence of previous synovectomy on the outcome after placement of a total elbow prosthesis.

METHODS

We inserted 204 primary Souter-Strathclyde total elbow prostheses for rheumatoid arthritis. Two groups could be distinguished: group A with previous synovectomy 3.9 yr (mean) before the elbow replacement (n = 33) and group B without previous synovectomy (n = 171). The mean follow-up was 5.8 yr for group A and 6.3 yr for group B. All patients were assessed clinically and radiologically before the operation, 1 and 2 years later and then at regular intervals. The effect of previous synovectomy was analysed via a Cox model and a generalized linear mixed model for binomial data with multivariate normal random effects.

RESULTS

No statistically significant effect of previous synovectomy on pain, function or complaints of the ulnar nerve could be found post-operatively. The post-operative flexion was significantly higher in group B than in group A. The complication-rates were similar for both groups. The overall survival rate for respectively group A and B with revision as endpoint was 66.9% (s.e. 13.4) versus 79.6 (s.e. 4.3) after 10 yr.

CONCLUSIONS

Previous synovectomy does not diminish the outcome after total elbow prosthesis in this series and could therefore be considered in early, painful stages of rheumatoid destruction of the elbow joint.

[Differential arthroplasty and endoprosthesis indications in rheumatoid arthritis of the elbow joint]

Management of patients with rheumatoid arthritis of the elbow has changed significantly over the last several years. From a medical standpoint, the disease-modifying agents have decreased the number of patients requiring a synovectomy. When synovectomy is indicated, arthroscopic synovectomy has lessened the morbidity of this procedure, but the long-term effectiveness as a definitive reconstructive procedure has yet to be determined. Both coupled and uncoupled elbow joint replacements have emerged as reliable interventions for this diagnosis. Mayo's experience with 78 patients with rheumatoid arthritis undergoing total elbow arthroplasty has revealed a satisfactory outcome of approximately 92% at 12 years. The complication rate is approximately 15% consisting primarily of delayed avulsions or deficiency of the triceps tendon (2%), deep infection (2%), and ulnar nerve irritation (3%).

Complications of thermal ablation in wrist arthroscopy

Wrist arthroscopy is a valuable diagnostic and therapeutic tool. Thermal ablation can be used concomitantly to treat partial ligamentous tears, triangular fibrocartilage cartilage complex tears, and to perform partial synovectomy. We reviewed 47 consecutive patients who underwent wrist arthroscopy with concomitant thermal ablation between 1997 and 2001. Three patients sustained serious complications. The serious complications included, in all three patients, tendon ruptures and in one case, a 5 x 10-mm full-thickness skin burn. Thermal treatment of collagenous tissues has recently gained popularity in the orthopedic literature, but there is little information on the potential complications. The arthroscopist of large and small joints must be aware of the risks involved when using thermal ablation.

Previous synovectomy or epiphyseal stapling and the influence on knee replacement in juvenile chronic arthritis

Seventy-seven anatomically graduated components (AGC) total knee arthroplasties (TKA) were performed on 52 patients with juvenile chronic arthritis. According to the nature of previous surgery on the knee, the patients were subdivided into three groups. The mean age at onset of disease in 23 patients with previous synovectomy of the knee was 11 (1.5-16) years, the mean age at the time of synovectomy was 20 (4-42) and the mean age when arthroplasty was performed was 31 (18-45) years. In nine patients with previous epiphyseal stapling, the mean age at disease onset was 4 (1.5-8) years, at stapling 8 (4-16) years, and at arthroplasty 23 (18-30) years. In patients with no previous surgery, the mean age at disease onset in this group was 7 (1.5-16) years and the mean age at arthroplasty 34 (16-64) years. Patients with need for epiphyseal arrest had an early disease onset and knee replacement in early adulthood. The mean age at knee replacements was highest in the group with no prior surgery.

A Comparison of Flexor Tenosynovectomy, Open Carpal Tunnel Release, and Open Carpal Tunnel Release with Flexor Tenosynovectomy in the Treatment of Carpal Tunnel Syndrome

The purpose of this study was to identify the advantages and disadvantages of performing a flexor tenosynovectomy without dividing the transverse carpal ligament, an open carpal tunnel release, and an open carpal tunnel release with flexor tenosynovectomy in the treatment of carpal tunnel syndrome. From 1990 to 1998, a retrospective study was done in which a flexor tenosynovectomy was performed in 133 patients without division of the transverse carpal ligament and compared with 68 patients who had an open carpal tunnel release and 75 patients who had an open carpal tunnel release and flexor tenosynovectomy. Patients were followed up for an average period of 30 weeks with history and physical findings and nerve conduction velocities and for an average period of 2.6 years with telephone interviews. There was a 2.3 percent incidence of pillar pain in the flexor tenosynovectomy group, which may explain the earlier return to their regular jobs at an average time of 9.9 weeks, compared with 10.7 weeks for the carpal tunnel release group and 12.0 weeks for the carpal tunnel release/flexor tenosynovectomy group. The latter two groups had an incidence of pillar pain of 12.1 percent and 25.3 percent, respectively. Postoperative grip strength was statistically significantly improved in the flexor tenosynovectomy group compared with the other two groups, where adjustments were made for sex and preoperative grip strengths with standard error of adjusted means. In the flexor tenosynovectomy group, 20.6 percent of patients had a previous open or endoscopic carpal tunnel release with recurrent carpal tunnel syndrome, compared with 5.2 percent in the open carpal tunnel release group and 21.6 percent in the open carpal tunnel release with flexor tenosynovectomy group. Excisional biopsies of flexor tenosynovium in the flexor tenosynovectomy, open carpal tunnel release, and open carpal tunnel release with flexor tenosynovectomy groups revealed an incidence of fibrosis in 89.2 percent, 88.9 percent, and 87.7 percent of specimens, respectively. Edema was a frequent finding, but an active inflammatory response was seldom seen. The findings in this study indicate that because of a significant decrease in pillar pain, a flexor tenosynovectomy in the treatment of carpal tunnel syndrome would likely benefit workers who use the palm of the hand in heavy manual or highly repetitive work by allowing them to return to regular duty sooner.

Lipoma arborescens of the knee: report of a case managed by arthroscopic synovectomy

We report a case of lipoma arborescens treated with an arthroscopic procedure. Lipoma arborescens is an uncommon pseudo-tumoral synovial lesion usually located in the suprapatellar pouch of the knee. This diagnosis should be considered, particularly in patients with chronic joint effusion. Magnetic resonance imaging confirms the lipomatous nature of the synovial proliferation. When limited to the anterior compartment of the knee, lipoma arborescens can be treated by arthroscopic synovectomy.

Subchondral cyst of the tibia secondary to Wilson disease

We present the case of a 40-year-old male patient who had been suffering from Wilson disease for over 20 years, whose knee was diagnosed as osteoarthritis combined with subchondral cyst of the tibia. Preoperative examinations (X-ray, CT and MRI) confirmed the diagnosis. The microscopic examination detected thickening of the synovial membrane, and histopathological findings revealed that lymphoid cells and plasma cells were infiltrated at the synovial membrane. On copper-specific staining, no copper pigmentation was identified. However, the energy-dispersive X-ray (EDX) microanalysis revealed copper pigmentation in high concentration. These findings may contribute to our better comprehension of the development process of the arthropathy in patients with Wilson disease. The combination of subchondral cyst with Wilson disease is extremely rare, as only about 16 such cases have been reported in the English literature.