Surgery on the rheumatoid ankle joint: efficacy versus effectiveness

This article examines synovectomy and ankle arthrodesis for the rheumatoid ankle joint. Reviews of osteoimmunology and gait analyses specific to rheumatoid arthritis are included. Comparison studies including ankle arthrodesis and total ankle arthroplasty are reviewed.

[Anesthetic management using esmolol for arthroscopic synovectomy in a patient with thyroid storm]

We report a case of a 47-year-old woman with past medical history of Graves disease who presented with thyroid storm, a state of physiologic decompensation due to severe thyrotoxicosis, and arthritis purulenta. Antithyroid therapy ameliorated thyrotoxicosis in 4 days, and arthroscopic synovectomy of the right knee was performed. Anesthesia was induced with intravenous propofol. Esmolol, an ultra-short-acting beta blocker listed in national drug tariff of Japan for intraoperative continuous iv infusion in March 2008, was also administered to control heart rate. Then, laryngeal mask airway was inserted and echo-guided femoral nerve block was done with ropivacaine. Anesthesia was maintained with i.v. infusion of propofol and fentanyl. Short episode of supraventricular tachycardia occurred twice, but each tachycardia disappered in about a half minute. The postoperative course was uneventful. Esmolol probably acted to prevent intraoperative tachycardia due to increased beta-adrenergic tone.

Arthroscopic treatment of patellar clunk and synovial hyperplasia after total knee arthroplasty

Patellofemoral pain, crepitus, and locking are infrequent symptoms after total knee arthroplasty (TKA). We performed a retrospective review of 25 patients who underwent arthroscopic debridement after primary TKA to treat the patellar clunk syndrome (15 knees) or patellofemoral synovial hyperplasia (10 knees). After surgery, patient-reported knee pain and crepitus as well as Knee Society knee and function scores improved in both groups. Postoperative knee range of motion remained unchanged. Arthroscopic debridement of symptomatic patellofemoral synovium after TKA is a safe and effective procedure.

Outcomes after excision of pigmented villonodular synovitis of the knee

Pigmented villonodular synovitis (PVNS) has a high but variable recurrence rate. Prior studies do not compare recurrence-free survival (RFS) for various surgical approaches or salvage surgery for relapse. We therefore determined: (1) RFS after excision; (2) RFS after salvage surgery for relapse; (3) factors associated with relapse. We retrospectively reviewed the medical records of 49 patients with previously untreated PVNS of the knee (12 localized, 37 diffuse) who were treated with synovectomy from 1991 to 2008; there were 22 males and 27 females, with mean age of 35.2 years (range, 10-73). Minimum followup was 1 year (mean, 6.2 years; range, 1-13). Twenty-one patients had a relapse. The RFS for index surgery was 75% and 53%; and for salvage surgery was 71% and 52% at 2 and 5 years respectively. The RFS was 95% for open versus 62% for arthroscopic synovectomy at 2 years, 71% and 41% at 5 years. The RFS was 91% for localized and 70% for diffuse PVNS at 2 years, 73% and 48% at 5 years. Diffuse disease (RR = 4.49) and arthroscopic synovectomy (RR = 3.30) were associated with relapse. Recurrence was frequent after synovectomy. Reexcision can salvage relapses as successfully as excision for primary disease; however, morbidity was associated with additional surgeries.

LEVEL OF EVIDENCE

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

Dose calculation from a D-D-reaction-based BSA for boron neutron capture synovectomy

Monte Carlo simulations were carried out to calculate dose in a knee phantom from a D-D-reaction-based Beam Shaping Assembly (BSA) for Boron Neutron Capture Synovectomy (BNCS). The BSA consists of a D(d,n)-reaction-based neutron source enclosed inside a polyethylene moderator and graphite reflector. The polyethylene moderator and graphite reflector sizes were optimized to deliver the highest ratio of thermal to fast neutron yield at the knee phantom. Then neutron dose was calculated at various depths in a knee phantom loaded with boron and therapeutic ratios of synovium dose/skin dose and synovium dose/bone dose were determined. Normalized to same boron loading in synovium, the values of the therapeutic ratios obtained in the present study are 12-30 times higher than the published values.

Diagnostic difficulties in pigmented villonodular synovitis. Presentation of cases

Pigmented villonodular synovitis is a rare entity. There are limited and diffuse, intra- and extraarticular forms. In the literature, this condition has been called xanthoma, xanthogranuloma, villous arthritis, pigmented villonodular synovitis, xanthomatous giant cell tumour, giant cell tumour of tendon sheath, giant cell fibrohemangioma, benign synovioma. The paper presents two cases in which, due to ignorance of this disease, patients were primarily qualified for oncological treatment: chemotherapy and radical resection or limb amputation. In both cases synovectomy produced good clinical outcomes although the procedures were not radical. It is necessary to unify the naming of pigmented villonodular synovitis because various names can be misunderstood by clinicians. Investigations indicating a non-inflammatory aetiology and reports of potential malignancy suggest that the terms inflammation or synovitis should no longer be used.

Orthopedic approach of haemophiliacs. A single center experience in Romania

Clinical expression of inadequately treated haemophilia is dominated by orthopedic complications, requiring invasive or non-invasive interventions.

OBJECTIVE

In Romania, with under dosed and late introduced "on demand" substitution, we aimed at highlighting the experience of orthopedic treatment and its outcome.

PATIENTS, METHODS

Single center retrospective analysis regarding orthopedic interventions and their outcomes was conducted on 59 hemophilia A, B, and von Willebrand disease patients, between 2002 and 2007.

RESULTS

The majority of interventions, invasive (60.71%) and non-invasive (39.28%), were elective, only two being emergencies. Postoperative functional evolution after synovectomies was good in 68.28%, fair in 24.39%, satisfactory in 7.31%. Results of 33 non-invasive (extensive releases) procedures were very good in 27.27%, good in 63.63%, poor in 9.09%.

DISCUSSION, CONCLUSIONS

The important number and complexity of orthopedic interventions are proving the precarious musculoskeletal state in persons with hemophilia, demonstrating the need of improving substitution, at least with discontinue prophylaxis in patients with severe forms.

[Minimally invasive therapy of rheumatoid cubarthritis]

With the progression of rheumatoid arthritis more than half of the patients develop an affection of the elbow. Rheumatoid arthritis is the most common cause of elbow arthritis. The complexity of the rheumatic disease, which typically affects many joints, demands an individual therapeutic plan that can only be developed and accomplished successfully, when rheumatologists, rheumatoid surgeons and other specialists cooperate. Consistent use of approved and improved pharmaceuticals is abating the rate of rheumatoid cubarthritis. In cases of recurrent cubarthritis despite adequate medication, adverse reactions and other problems should be borne in mind before making a decision to change to more aggressive medication or synovectomy. Minimally invasive local measures, such as synoviorthesis and arthroscopic synovectomy can relieve pain and swelling, however, if lesions of the cartilage already exist, progressive joint destruction cannot be prevented. In early phases of rheumatoid cubarthritis with tight ligaments and thin synovial lining we prefer synoviothesis. In cases with recurrent cubarthritis after synoviorthesis or strong proliferation of the tunica synovialis, arthroscopic synovectomy is advantageous. Arthroscopic synovectomy is most effective in cases when there is ligament laxity in the sense of a late synovectomy, as removal of loose bodies, smoothening of the cartilage, release of the joint capsule and possibly arthroscopy-assisted resection of the radius head can be performed.

SAPHO syndrome - rare case of joint damage treated by knee synovectomy and total hip joint replacement

This report describes the case of a young male who had been followed-up between the ages of 14-21 years at different health facilities for symptoms initially considered to be caused by tumor, then by chronic osteomyelitis or ankylosing spondylitis and finally diagnosed as the SAPHO syndrome. Musculoskeletal symptoms of the SAPHO syndrome include focal, probably aseptic chronic osteomyelitis, synovitis and formation of hyperostoses. Therapy of the SAPHO syndrome is predominantly conservative. However, in this case we had to employ arthroscopic synovectomy first, for severe synovitis resistant to any conservative therapy approach. Later, left total hip replacement has been performed for advanced hip joint damage accompanied by intense pain and significant range of motion reduction. At the present time, the patient is 51/2 years after synovectomy of the knee and 5 years after the hip joint replacement. The knee joint is without effusion or functional limitations, with intermittent pains only. The hip prosthesis in the risk area is fully integrated without signs of component loosening, with very good functional outcome. While synovectomy can be obviously fully recommended in cases like this, the total joint replacement should be considered unique and indicated only rarely after careful consideration of all circumstances.We consider this approach absolutely exceptional also because we have not found reference to similar case in any national or international professional literature available.

Immunohistological assessment of the synovial tissue in small joints in rheumatoid arthritis: validation of a minimally invasive ultrasound-guided synovial biopsy procedure

The aim of the present study was to perform an immunohistological assessment of the synovial tissue from involved small joints in rheumatoid arthritis (RA) and to explore the reliability of a mini-invasive ultrasound (US)-guided technique of small joint synovial biopsy for the histopathological assessment. Synovial tissue collected during arthrotomic surgery of small joints in nine patients served as the gold standard for the validation of the histological assessment. Small hand-joint synovial biopsies from an additional nine patients with erosive RA were obtained by a mini-invasive US-guided procedure, performed percutaneously by the portal and rigid forceps technique. Using digital image analysis, the area fractions of synovial macrophages (CD68 cells), T cells (CD3 cells) and B cells (CD20 cells) were measured in all high-power fields of every sample at different cutting levels. The representative sample was defined as the minimal number of high-power fields whose mean area fraction would reflect the overall mean area fraction within a percentage mean difference of 10%. For each patient, a range of three to five large samples for surgical biopsies and a range of 8–12 samples for US-guided biopsies were collected and analysed. In arthrotomic samples, the analysis of a randomly selected tissue area of 2.5 mm² was representative of the overall value for CD68, CD3 and CD20 cells. US-guided samples allowed histological evaluation in 100% of cases, with a mean valid area of 18.56 mm² (range 7.29–38.28 mm²). The analysis of a cumulative area of 2.5 mm² from eight randomly selected sections (from different samples or from different cutting levels) allowed to reduce the percentage mean difference to less than 10% for CD68, CD3 and CD20 cells. In conclusion, US-guided synovial biopsy represents a reliable tool for the assessment of the histopathological features of RA patients with a mini-invasive approach.

Biocompatibility testing of simulated total joint arthoplasty articulation debris

Surface characterization was performed to evaluate the surface condition of an uncoated cobalt alloy disc (control), and discs with medium and thick boron coatings for total joint articulating surfaces. Discs were characterized by scanning electron microscopy before and after dissolution studies. Chemical analyses of elemental transfer to the solution were assessed to evaluate the surface stability of the new coating. An in vivo biocompatibility study for particulates [of boron (B), titanium alloy (Ti), cobalt alloy (Co), and combinations of B + Ti and B + Co] was performed using a rat air pouch model. The inflammatory reactions to particulates were evaluated histologically and histochemically. No physical alteration was seen in the discs after the dissolution studies, and the elemental transfer to the dissolution solution was minimal. The cytokines, tumor necrosis factor (TNFalpha), and histology results from these simulated debris showed similar and moderate level responses magnitudes for the boron and mixtures and the primary alloy particulates. The conclusion from this initial study was that assessments of the coated discs showed physical properties similar to control. Also results from the in vivo studies of simulated wear debris from boron coatings on titanium and cobalt alloys demonstrated biocompatibility profiles that were mild to moderate and similar to prior analyses of wear debris products in synovial pouch models.

Long-term results after arthroscopic treatment of synovial chondromatosis of the shoulder

PURPOSE

The purpose of this study was to document the results of arthroscopic treatment for synovial chondromatosis of the shoulder with loose body removal and partial synovectomy.

METHODS

Five cases of shoulder arthroscopy performed for synovial chondromatosis were reviewed. Removal of loose bodies and partial synovectomy was performed in all cases. Follow-up of 4 to 9 years was obtained on these 5 patients.

RESULTS

The clinical result was very good for all patients. Radiologic signs of chondroma were observed in two patients. Revision surgery was not necessary in either case.

CONCLUSIONS

The clinical results referring to the Constant and Murley score and subjective assessment were very good at 4 to 9 years following surgery. However, in two out of five subjects, radiographs revealed evidence of persisting or recurrent synovial chondroma at follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic synovectomy in haemophilia: indications, technique and results

Recurrent spontaneous haemarthrosis are commonly seen in patients affected by haemophilia. The knee and the elbow are most commonly affected and both are amenable to arthroscopic treatment. Arthroscopic synovectomy is indicated after failure of appropriate medical management with recurrent bleeding. Many patients also demonstrate motion loss and functional deterioration. The benefits of arthroscopic synovectomy include the ability to perform adequate synovial debridement, but also concomitant lysis of adhesion and capsular release to regain range of motion. Results of arthroscopic synovectomy demonstrate a significant decrease in episodes of haemarthrosis, and significant improvement in pain, range of motion and function. The primary predictor of outcome is degree of pre-existing degenerative changes within the joint. In more severe cases, the results of arthroscopic synovectomy are unpredictable and serious consideration should be given to primary arthroplasty.

[Conservative local therapy of inflammation of joints: local invasive forms of therapy]

Local invasive procedures represent possibilities for the treatment of arthritic swollen joints without surgical interventions, when general measures alone are not successful and intra-articular injections are of utmost importance in this context. The differences between degenerative and rheumatologic diseases must be considered as well as possible specific adverse reactions, side effects and contraindications. The technical intervention is performed according to the guidelines of scientific societies such as the Scientific Medical Profession Society (AWMF). Cortisone and radiosynoviorthesis/chemosynoviorthesis are suitable for activated rheumatic and degenerative joints, low-grade radiation therapy or infiltration of hyaluronic acid is recommended for relief in cases of arthritic inflammation. The combination of arthroscopic synovectomy and subsequent radiosynoviorthesis in the early stages of rheumatically swollen joints show the best results with respect to regression prophylaxis and slowing the process of rapidly progressing destruction of chondral surfaces and distension of the capsules and ligaments.

Arthroscopic treatment of patellofemoral soft tissue impingement after posterior stabilized total knee arthroplasty

Patellar clunk syndrome is due to a suprapatellar fibrous nodule which develops at the junction between the proximal patella and the quadriceps tendon after total knee arthroplasty. Twelve patients (12 knees) who underwent arthroscopic treatment for the painful patellar crepitus or clunk after total knee arthroplasty had been followed at least for 1 year were enrolled. The average onset of symptom was 10.2 months (from 3 to 21 months) after total knee arthroplasty. All of the patients presented a painful crepitus, catching or clunk at the proximal patella, especially climbing stairs or rising from sitting. Both radiographic and clinical evaluations were done and for the clinical assessment, Knee Society Scores were recorded preoperatively and postoperatively. On their radiographic assessment, there was no evidence of component failure and in only one patient, joint line was elevated more than 8 mm. On arthroscopic examination, hypertrophic synovial tissue was identified at the junction of patella and quadriceps tendon in all patients. The hypertrophic synovial tissue did not engage completely in the intercondylar notch during flexion, but on extension, the lesion impinged on the distal part of anterior flange of femoral component at about 30 degrees to 40 degrees of knee flexion. On clinical assessment at the latest follow-up, the average knee score and function score increased from 63.8+/-4.6 to 90.9+/-3.2, 65.4+/-3.2 to 90.4+/-4.3 respectively. Arthroscopic debridement for soft tissue impingement at the patellofemoral joint following total knee arthroplasty showed satisfactory results.

Arthroscopic, macroscopic, and microscopic anatomy of the synovial fold of the elbow joint in correlation with the common extensor origin

PURPOSE

The objective of our study was to clarify the arthroscopic, macroscopic, and microscopic anatomy of the radiocapitellar synovial fold of the elbow joint in correlation with the common extensor origin.

METHODS

We performed arthroscopy in 14 fresh-frozen cadaveric elbows and found the synovial fold covering the radial head or interposing in the radiocapitellar joint in 6. The fold was tagged with loop suture under arthroscopy to identify its exact location in gross anatomy. The radiocapitellar joint capsule was then resected without disturbing the continuity of the common extensor and lateral epicondyle. Macroscopic and histologic evaluation was performed for the lateral elbow capsular complex.

RESULTS

The synovial fold was found to be a triangular-shaped thickening of the capsule located on the proximal edge of the annular ligament. The mean distance between the lateral epicondyle and the base of the fold at the anterior edge, middle part, and posterior edge was 23 mm, 8 mm, and 13 mm, respectively. This structure was distinct from the annular ligament but was continuous with the radiocapitellar joint capsule. The joint capsule and the common extensor tendon blended with each other imperceptibly and formed a single enthesis at the lateral epicondyle.

CONCLUSIONS

The synovial fold identified by arthroscopy is a physiologic capsular tissue located on the proximal edge of the annular ligament. It is distinct from the annular ligament but has a close correlation with the common extensor tendon enthesis at the lateral epicondyle.

CLINICAL RELEVANCE

The synovial fold belongs to the lateral epicondyle enthesis, which is a composite of the common extensor tendon, undersurface capsule, and bone. Therefore, lateral epicondylitis with degenerative lesions in the area of the common extensor origin may involve the synovial fold and induce hypertrophic changes.