Arthroscopic treatment of synovial chondromatosis that possibly developed after open capsular shift for shoulder instability

Synovial chondromatosis is a rare disease with an unknown etiology, and can be defined as a synovial process characterized by the formation of metaplastic cartilaginous foci inside the connective tissue of articular surfaces. The disease is classified as primary or secondary. The cause of primary disease is unknown, but its pathogenesis involves the development of chondroid foci in synovial membranes. Secondary disease is caused by synovial tissue pathophysiologies, such as, trauma or infection, adjacent to an involved joint. Plain radiographs reveal multiple calcific nodules in glenohumeral joints. However, X-ray diagnosis is often delayed and extremely difficult when the disease is not calcified. Magnetic resonance imaging (MRI) and computed tomography are helpful. For treatment, open or arthroscopic synovectomy and loose body removal are recommended. The authors experienced a rare case of radiologically non-visible synovial chondromatosis, which was viewed as the cause of postoperative residual pain and limitation of motion in a young male with open capsular shift. This case report is presented to emphasize the role of arthroscopy and MRI in the early diagnosis and treatment of synovial chondromatosis.

Arthroscopic synovectomy in rheumatoid arthritis of wrist

The wrist is the most commonly involved region of the upper extremity in rheumatoid arthritis (RA). Because the wrist joint becomes involved early during the disease course and its involvement rapidly progresses, and because the disabilities associated with progressive RA are significant, early and adequate treatment must be introduced to prevent disease progression. Various treatment methods can be employed to treat RA wrists based on radiological and clinical findings. Arthroscopic synovectomy is recommended for pain relief and functional recovery in early stage RA, and is also helpful in advanced staged RA with Larsen stage III. However, arthroscopic synovectomy is not recommended as an effective method of treatment for all patients with advanced radiographic changes. Nevertheless, arthroscopic synovectomy may delay the need for complex surgery, such as wrist arthrodesis or total wrist arthroplasty in selective cases. Although arthroscopic synovectomy of the wrist cannot improve grip strength or range of motion, it can reduce wrist pain and improve function, and thus facilitate return to work.

Synovial knee affected in multiple hemangiomatosis

Synovial hemangioma is a vascular lesion of joint cavities. It is a rare cause of pain and spontaneous hemarthrosis in the paediatric age group. It is often seen as an internal derangement of the knee. We present the case of a 37-year-old woman with a history of recurrent effusions of this joint. The MRI showed a soft tissue mass affecting the Hoffa's fat pad and the synovial surrounding the patella. Other hemangiomas were detected in other sides of the body. Through arthroscopy, we eliminated all the pathological tissue of the knee. The patient remains asymptomatic after 1 year.

[Tenosynovial giant cell tumour of the hand and wrist: early diagnosis and surgical treatment]

Fourty two patients with tenosynovial giant cell tumour, treated with radical excision, underwent detailed follow-up to evaluate the outcomes and to find early the possible recurrence of disease. Radical excision is the only way to have a complete recovery from disease and total recovery of function. Early diagnosis of recurrence is possible by careful clinical examination, ultrasonography and, in selected cases, magnetic resonance imaging.

Outcome of 17 pigmented villonodular synovitis (PVNS) of the knee at 6 years mean follow-up

Between January 1950 and December 2000, 16 patients were identified from Scottish Bone Tumour Registry with 17 histologically proven pigmented villonodular synovitis (PVNS) of the knee. The mean follow-up was 6 years (range, 1-14 years). A knee swelling of chronic duration with dull ache was the common presenting symptom. The mean duration of symptoms prior to presentation was 25 months (1-108 months), however it was much less (mean, 7 months) in four patients with a history of trauma. The mean age was 33 years (range, 16-58 years) with a slight male predominance. The lesion was predominantly anterior in nine patients, posterior in four, anterolateral in two, and medial and lateral in one each. Three patients (four knees) had localised disease and 13 diffuse. Anteroposterior and lateral radiographs of the knee revealed normal findings in 11 patients, features of gonarthrosis in four and a large suprapatellar loose body in one patient (both knees). Open (incisional-eight, excisional-eight) biopsy was carried out in all and all were histologically confirmed as PVNS. Removal of a localised synovial mass or loose body with surrounding partial synovectomy (four) was carried out for the localised variety, whilst open partial (three) or total (radical) synovectomy (10) was performed in all cases of diffuse PVNS. Three of seventeen knees had a recurrence, noted at 4, 6 and 8 years postoperatively (0% - localised, 23% - diffuse variety). A total (radical) synovectomy should be considered in diffuse PVNS in order to obtain optimal outcome.

[Surgical procedures for treatment of the rheumatoid knee]

In the last decade considerable modifications in the surgical procedures recommended for the treatment of rheumatoid knee have been observed. This was due to all the medical developments achieved in pharmacology and therapeutic as well as a significant quality improvement of the rheumatologist s intervention. The synovectomy and namely the total knee arthroplasty represent the most commonly procedures used in the surgical treatment of the rheumatoid knee. An arthroscopic followed by a radionuclide synovectomy can be an appropriate treatment in a knee with an inflammatory arthritis Larsen radiograph grade I II . The ideal patient for synovectomy must present an early disease absence of deformity or instability good range of motion and preserved articular cartilage. On the other hand a total knee arthroplasty represents the only possible operation to treat a rheumatoid knee with a severe bone and cartilage damage Larsen radiograph grade IV V including younger patients. Total knee arthroplasty is actually a successful operation providing pain relief and the restoration of the function. Nevertheless the excellent good short and medium-term results achieved do not resist over time. Similarly to what happens with every other arthoplasty joint replacements the particules that come from the wear of the biomaterials included in its composition are the cause of biological intolerance reactions which can lead to the need of a new implant. The replacement prosthesis raises technical issues related to the reconstruction of bone mass losses where the cryopreserved bone allografts can be recommended.

[Acromelic arthritis: a new entity]

PURPOSE OF THE STUDY

Few patients with rheumatoid arthritis present isolated acromelic bone and joint destructions. Concerned joints are wrist, MP, PIP, DIP and forefoot. The aim of the current study is to describe and evaluate the long-term results of wrist, hand and forefoot surgery in an acromelic arthritis group.

MATERIAL AND METHODS

93 patients with acromelic arthritis were included in the study. 202 surgical procedures were performed between 1981 and 2001 in addition to medical treatment. 93 procedures concerned dorsal wrist surgery. The mean follow-up of this group was 7 years (24 months-20 years). 78 synovectomies of radio-carpal and medio-carpal joints with a Sauvé-Kapandji procedure were performed and 10 with a radio-lunate arthrodesis and 5 with other surgeries. The main indication for surgery was severe pain.

RESULTS

Functional results and radiographic evolution (Larsen X-ray classification) were studied. All patients were satisfied or very satisfied and pain was significantly reduced. Radiographic lesions progressed but Larsen's stage remained unchanged in 73% of patients. All patients with forefoot surgery recovered total walk autonomy.

DISCUSSION

Acromelic arthritis is a particular form of rheumatoid arthritis that progresses very slowly. Surgery should be indicated earlier, for a better joint function stabilisation.

Radial head excision and synovectomy in patients with hemophilia

BACKGROUND

Chronic hemophilic synovitis of the elbow usually leads to enlargement and erosion of the radial head, resulting in mechanical blockage of forearm rotation, synovial impingement, recurrent hemarthrosis, and pain. The purpose of the present study was to evaluate the intermediate-term results of radial head excision and synovectomy in a large group of patients with hemophilia who had been managed at a single institution.

METHODS

Information on forty radial head excision and synovectomy procedures that had been performed at our institution from 1969 to 2004 was retrospectively collected. All but one of the operations had been performed in patients with severe hemophilia. The mean age of the patients at the time of the procedure was thirty-three years. Pain, limited range of motion, and bleeding were the indications for surgery. The mean duration of follow-up was 7.7 years.

RESULTS

Only one postoperative complication was observed: a posterior interosseous nerve palsy that fully resolved by six months. No additional surgical intervention for bleeding was required in sixteen of the nineteen elbows in which bleeding was one of the indications for surgery. Of the forty elbows, seven required a secondary surgical procedure at a mean of five years after the excision of the radial head. Examination of the mean range of motion at the time of the latest follow-up demonstrated a 63 degrees increase in the pronation-supination arc (p < 0.00001) but only a 2 degrees increase in the flexion arc.

CONCLUSIONS

Radial head excision in patients with hemophilia is an effective procedure for improving forearm rotation and reducing pain and bleeding frequency, with a low risk of complications.

Colloidal 90Y used for radiation synovectomy decreases the viability of chondrocytes in human cadaveric samples

OBJECTIVE

To analyse the early effect of colloidal 90Y beta irradiation, as used for radiation synovectomy (RSV), on the viability of human chondrocytes in an ex-vivo model.

METHODS

Twenty osteochondral plugs (6 mm in diameter) were procured from femoral condyles of an adult male donor and stored in normal saline at 4 degrees C. The cartilage surfaces of 10 plugs were contaminated with colloidal 90Y citrate corresponding to the standard knee RSV dose (185 MBq) matched for the sample size (430 kBq). The remaining 10 plugs served as controls. At days 1, 2, 3, 6 and 13, two osteochondral plugs from each group were stained for viability with live/dead probes and scanned under a confocal laser microscope. The ratios of viable (green channel) and non-viable (red channel) pixels were acquired in four cartilage depth regions and statistically analysed with a regression model.

RESULTS

The irradiation did not significantly alter the viable/non-viable pixel ratio during the first 2 days, but longer exposures led to a significant and time progressive reduction from 8.7% (day 3) to 12.5% (day 13). The ratio was less affected deeper in the cartilage, where it increased about 1% for every 100 microm from the surface.

CONCLUSIONS

Surface exposure of human cadaveric cartilage to a therapeutic dose of colloidal 90Y decreased chondrocyte viability, expressed as the viable/non-viable pixel ratio, in the early post-irradiation period. The findings established in the ex-vivo simulation may reflect the changes in knee cartilage occurring after RSV therapy.

Synovectomy of the hip in patients with juvenile rheumatoid arthritis

BACKGROUND

There is a lack of data on the functional effect of open hip synovectomy in a large number of patients with juvenile rheumatoid arthritis evaluated with a validated assessment tool.

METHODS

Between 1985 and 1997, sixty-seven open hip-joint synovectomies were carried out in fifty-six patients with juvenile rheumatoid arthritis. Fifty-five hips (82%) had radiographic changes that were stage III or higher according to the system of Larsen et al. Hip function was evaluated preoperatively and after a mean of fifty months with the Merle d'Aubigné hip score.

RESULTS

Sixty-five (97%) of the sixty-seven hips were available for follow-up. The mean total Merle d'Aubigné hip score (and standard error of the mean) was significantly improved from 9.5 +/- 2.5 points at baseline to 16.3 +/- 1.0 points at the time of follow-up (p < 0.001). The individual scores for pain, mobility, and walking ability were significantly increased as well (all p < 0.001). Eighty-five percent of the hips were observed to have a very great or great improvement in function. A concomitant soft-tissue release was performed in seven hips, and nine hips required surgical dislocation. Surgical complications included two superficial wound hematomas that did not require intervention; osteonecrosis of the femoral head was not observed. Five hips required total hip arthroplasty during the follow-up period. Thus, the survival rate for the hips was 94% at a mean of four years following the synovectomy.

CONCLUSIONS

Open hip synovectomy in patients with juvenile rheumatoid arthritis is a safe procedure that can improve hip-joint function for up to five years.

Early clinical results of open and arthroscopic synovectomy in knee inflammation

BACKGROUND

The authors compared early results of open and arthroscopic knee joint synovectomy in patients with nonspecific exudative synovitis and rheumatoid arthritis.

MATERIAL AND METHODS

The study comprised two groups of patients matched for age, preoperative range of motion in the involved knee and etiology of synovitis. Group I included patients after open synovectomy and group II consisted of subjects following an arthroscopic procedure. Blood loss, analgesic intake, duration of hospitalization, range of flexion and extension in the involved knee at discharge as well as 3 and 6 months following surgery were compared, together with respective recurrence rates.

RESULTS

A statistically significant decrease in blood loss and a shorter duration of hospitalization were found in group II compared to group I; no differences were observed in postoperative analgesic use. Mean flexion range was significantly greater before surgery than in the 3 analyzed time intervals in both study groups except for knee flexion in group II compared before and 6 months following the intervention. However, mean flexion range in the operated joint at discharge and 3 months postoperatively was significantly greater in group II as compared with group I. A comparison of the knee extension range between the groups revealed significantly higher values in group II at discharge, but no statistically significant differences were found in the subsequent follow-up assessments. However, flexion contractures developed 6 months after surgery in 5 patients from group I and in 1 patient from group II. No recurrence of effusion was observed in either group.

CONCLUSIONS

According to the authors, arthroscopic synovectomy reduces blood loss following surgery, shortens duration of hospitalization and permits faster recovery.

Arthroscopic treatment of symptomatic type D medial plica

We aimed to review the results of subtotal arthroscopic resection of symptomatic type D medial plica. We retrospectively evaluated 23 knees with symptomatic type D medial plica in 22 patients without other intra-articular pathology. All patients complained of chronic knee pain that had not been alleviated by medical treatment or physical therapy. In only three (13%) of the patients studied was the plica diagnosed pre-operatively with magnetic resonance imaging. The type D medial plicae in our series were classified as fenestrated (14 knees), torn (5 knees), or reduplicated (4 knees). Fibrotic changes in the plicae and degenerative changes on the medial femoral condyle were found in 16 knees Patellofemoral chondromalacia was present in three knees Arthroscopic partial resection was performed in all patients. Comparative Lysholm Knee Scale scores before and after surgery revealed a significant clinical improvement (pre-operative status, 67.19 +/- 8.05 vs. post-operative status, 90.57 +/- 9.80; P < 0.001). Type D medial plica should be considered as a possible cause of chronic knee pain. Arthroscopic partial resection of the plicae in symptomatic patients gives satisfactory results.

[Operative differential therapy of rheumatic wrists]

The wrists are affected in the long-term in 90% of people with rheumatism and are often (42%) the first manifestation of a destructive disease. The functionality of the wrist and the whole hand is of great importance because in many cases loss of function of the wrists leads to severe limitations. Local and operative treatment of the wrist in rheumatoid arthritis (RA) is one of the main duties in rheuma-orthopaedics. For operative treatment there is a finely tuned differential therapeutic spectrum available. The diagnostic indications take the local and total pattern of affection, the current systemic therapy as well as patient wishes and patient compliance into consideration. In the early stages according to LDE (Larsen, Dale, Eek), soft tissues operations such as articulo-tenosynovectomy (ATS) are most commonly carried out. In further advanced stages osseus stabilisation must often be performed. At this point a smooth transition from partial arthrodesis to complete fixation is possible. After initial euphoria, arthroplasty of the wrist is being increasingly less used for operative treatment due to the unconvincing long-term results and high complication rate. With reference to the good long-term results of all operative procedures, in particular early ATS with respect to pain, function and protection of tendons, after failure of medicinal treatment and persistence of inflammatory activity in the wrist, patients should be transferred to an experienced rheuma-orthopaedic surgeon.

A case of pachydermoperiostosis treated by oral administration of a bisphosphonate and arthroscopic synovectomy

Pachydermoperiostosis (PDP) is a rare hereditary disorder characterized by pachydermia, digital clubbing, and periosteal hypertrophy. Here, we report a case of PDP showing symptoms consistent with arthritis, which was treated by oral administration of risedronate sodium and arthroscopic synovectomy.

Treatment of early basal joint arthritis using a combined arthroscopic debridement and metacarpal osteotomy

Osteoarthritis of the thumb basal joint is a common and disabling condition, and early stages of which are often seen in middle-aged women. Arthroscopic assessment of the first carpometacarpal joint allows easy identification and classification of joint pathology with minimal morbidity. This allows the condition to be managed either arthroscopically or converted to an open procedure as indicated. Different procedures have been described to treat different stages of this disease. The senior author has recently described an arthroscopic staging system to determine treatment for basal joint osteoarthritis. We now present our surgical technique and early clinical experience with arthroscopic synovectomy, debridement, and corrective osteotomy for arthroscopic stage II of thumb basal joint arthritis. Forty-three patients (38 women and 5 men) were arthroscopically diagnosed as having stage II basal joint osteoarthritis of the thumb between 1998 and 2001, and they were the focus of the present study. In all the patients, there was no improvement after a period of 6 to 12 weeks of conservative treatment. All the procedures were performed by the senior author. The surgical procedure included arthroscopic synovectomy, debridement, and occasional thermal capsulorraphy, followed by an extension-abduction closing wedge osteotomy in all the cases. A 0.045-in Kirschner wire provided stability to the osteotomy. By performing an osteotomy that redirects the axial loads in this joint, we have obtained satisfactory results in terms of pain relief, stability, and pinch strength. Arthroscopy allows us to not only determine the optimum indication for this osteotomy, but also to debride the joint and minimize the inflammatory response. Hence, we recommend arthroscopic synovectomy, debridement with or without a thermal capsulorraphy, and a dorsoradial closing wedge osteotomy for the treatment of arthroscopic stage II of thumb carpometacarpal joint osteoarthritis.

Synovial chondromatosis of four compartments of the knee: medial and lateral tibiofemoral spaces, patellofemoral joint and proximal tibiofibular joint

A case of synovial chondromatosis of the proximal tibiofibular joint in addition to lateral and medial tibiofemoral spaces and patellofemoral joint has been presented.

Late spontaneous haemarthrosis: an unusual complication following an unicompartmental knee arthroplasty

A man, aged 55, presented with a spontaneous haemarthrosis of his right knee, 1 year after an unicompartmental knee replacement. This case showed an atraumatic rupture of the metal marker wire of an all-polyethylene inlay tibial implant which caused a destruction of the polyethylene surface and a disseminated synovitis of the right knee. This is a rare but destructive complication following an unicompartmental knee arthroplasty.

Radiation Exposure of Hemophiliacs After Radiosynoviorthesis with 186Re Colloid

Very limited data are available in the literature on the doses of unwanted radiation that patients receive following treatment with radiosynoviorthesis (RSO).

OBJECTIVE

The aim of this study was to assess the radiation exposure after RSO with (186)Re colloid in hemophiliacs.

METHODS

This study involved 12 hemophiliacs who were treated for hemophilic joint disease with 14 RSOs by using (186)Re colloid. Whole-body scintigrams were performed 1, 6, and 24 hours and 3 and 7 days after RSO. Measurements, using a whole-body counter, were done immediately after scintigraphy, with the treated joint protected with a lead shield. The cumulative activity of (186)Re in the body and in the lymph nodes was calculated. The distribution of (186)Re in the body was determined by using the values for small colloids as proposed by the International Commission on Radiological Protection (ICRP) Publication 53. The computer code, OLINDA/EXM (Vanderbilt University, Nashville, TN), was used for the calculation of the internal dose. A constant distance of 1 m between the ankle joint and body organs, and of 0.33 m between the elbow or shoulder joint and body organs, was used to calculate the contribution of gamma radiation to the effective radiation dose.

RESULTS

The mean effective dose received by hemophiliacs after RSO with (186)Re colloid was 28 +/- 9 microSv/MBq of the activity injected into the joint. The patients received 0.8-3.7 mSv (1.9 +/- 0.8 mSv) owing to the leakage of (186)Re from the treated joint and its retention in the body. The highest doses were established in the spleen (26.0 +/- 10.7 mGy), the liver (17.6 +/- 7.2 mGy), and red marrow (3.0 +/- 0.8 mGy). The contribution of gamma radiation to the effective dose was less than 0.1 mSv in RSO of the ankle, 0.4 mSv in the elbow, and 0.6 mSv in the shoulder-joint treatment. The activity of (186)Re in the regional lymph nodes was noted in 4 of the 14 treatments. In these cases, the estimated average dose received by individual lymph nodes was 14.7 +/- 1.9 Gy.

CONCLUSIONS

RSO with (186)Re colloid is a safe treatment method. The effective dose received by patients after RSO by using (186)Re colloid is low, as are the radiation doses to the most exposed organs. If (186)Re is retained in the regional lymph nodes, the lymph node radiation dose would be high.

Synovial hemangiohamartomas of the knee joint

Hemangioma or vascular malformation of the synovium is rare and presents a difficult problem in diagnosis and treatment. A long history of joint pain and recurrent non-traumatic hemarthrosis usually draws attention to the hemangioma of the knee joint. The lesion can be seen in two different formations; the synovial hemangioma or the arteriovenous malformation named as hemangiohamartomas, both of which involve the synovium and cause non-traumatic episodes of hemarthrosis. MRI scanning together with arthroscopy is a diagnostic tool to demonstrate the extent and the nature of the lesion. We treated the three patients at different ages. All patients underwent standard radiographic examination, CT scans, MRI and diagnostic arthroscopy. After frozen section taken via arthroscopically, the lesions were excised by arthrotomy. The mean follow-up was 38 months (31-45) and all patients are asymptomatic postoperatively. Three additional cases and a review of the literature are presented because of the rarity of the lesion.

Treatment of chronic pain in pediatric rheumatic disease

Pain in children with rheumatic disease is common, and is most often caused by arthritis. Despite the widespread use of effective new biologic agents, pain continues to be a problem in these patients, and it greatly impairs their daily functioning and quality of life. The pathogenesis of pain in children with rheumatic diseases is multifactorial, and disease treatment alone is often not enough to alleviate it. No standard of care or detailed algorithm for managing pain in these patients exists. Specific pain treatments often include acetaminophen, NSAIDs and medications that treat arthritis, such as methotrexate and etanercept. Other approaches should include nonpharmacologic interventions, for example exercise and cognitive-behavioral therapy, as well as the use of analgesics such as opioids in patients whose pain is refractory to standard therapies. The use of systemic corticosteroids to treat pain in children with arthritis should be avoided.

Arthroscopic interpositional arthroplasty for Freiberg's disease

Freiberg's disease is a relatively rare condition and can be difficult to manage, especially in those with late stages. Surgical treatment should be considered if conservative treatment cannot relieve the symptoms. We describe an arthroscopic interpositional arthroplasty for extensive late stages (stage IV or V) Freiberg's disease. Metatarsophalangeal arthroscopy is performed with dorsolateral and dorsomedial portals. Loose body is removed and joint surfaces are debrided. Extensor digitorum brevis tendon graft is harvested and rolled and brought into the joint. The technique is easy and can be performed on outpatient basis.

Synovial chondromatosis presented as knocking sensation of the knee in a 14-year-old girl

Knee joint is the most common site of synovial chondromatosis with the prevalence in middle-aged male. The following is the description of a 14-year-old girl presented with a knocking sensation during the motion of her joint, which is a less common occurrence at her age. Loose bodies in the left knee joint were excised as much as possible with arthroscopy. The patient was asymptomatic when moving her knee after arthroscopic synovialectomy and removal of the loose bodies. In spite of the less possibility of malignant transformation of synovial chondromatosis, long-term follow-up is still recommended in this 14-year-old girl due to the supposed genetic abnormalities.