Arthroscopy in primary synovial chondromatosis of the hip: description and outcome of treatment

Longitudinal Assessment of Clinical Outcomes After Arthroscopic Treatment for Hip Synovial Chondromatosis and the Effect of Residual Loose Bodies: Minimum 4-Year and 8-Year Follow-up

BACKGROUND

Arthroscopic treatment is recommended for hip synovial chondromatosis. However, evidence regarding long-term clinical outcomes is limited.

PURPOSE

To evaluate long-term patient-reported outcomes (PROs) and survival, and to determine the potential effect of residual loose bodies, as evaluated by immediate postoperative computed tomography (CT), on clinical outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A consecutive cohort of patients undergoing arthroscopic treatment and diagnosed with synovial chondromatosis between March 2010 and May 2015 were included in the study. Preoperative radiography, CT, and magnetic resonance imaging were performed. Preoperative, midterm (minimum of 4 years), and long-term (minimum of 8 years) PROs were collected for visual analog scale for pain, modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and 12-item international Hip Outcome Tool (iHOT-12). The percentages achieving minimal clinically important difference (MCID) were calculated. PROs and survival were compared between patients with and without residual loose bodies evident on immediate postoperative CT scan.

RESULTS

A total of 28 patients (20% of patients were lost to follow-up) were included in the study with a mean follow-up period of 104.9 months (range, 96-139 months). PROs including visual analog scale for pain (preoperative, 3.8 ± 1.2; midterm, 0.9 ± 1.7; long-term, 0.8 ± 1.4), mHHS (preoperative, 66.4 ± 14.4; midterm, 92.8 ± 12.3; long-term, 93.5 ± 10.5), NAHS (preoperative, 45.2 ± 16.2; midterm, 81.8 ± 15.3; long-term, 83.1 ± 12.9), and iHOT-12 (preoperative, 48.4 ± 15.6; midterm, 69.3 ± 11.7; long-term, 72.7 ± 11.4) were improved at both midterm and long-term follow-up (all with P < .001). In total, 27 (96.4%), 28 (100%), and 26 (92.9%) patients achieved MCID for mHHS, NAHS and iHOT-12, respectively, at the long-term follow-up. No significant difference was found in any of the PROs and the rate of achieving MCID between midterm and long-term follow-up (all with P > .05). One patient (3.6%) underwent revision surgery. Among the 23 patients who had loose bodies on preoperative CT or radiographs, 14 patients (60.9%) with residual loose bodies evident on immediate postoperative CT demonstrated lower NAHS (P = .045) and iHOT-12 (P = .037) scores but a comparable survival (P > .05) at long-term follow-up compared with those who did not have loose bodies.

CONCLUSION

Arthroscopic treatment for hip synovial chondromatosis achieved satisfactory long-term clinical outcomes with strong survival. Most patients maintained or improved their overall functional status between midterm and long-term follow-up. Furthermore, patients with residual loose bodies had less favorable clinical outcomes, although the survival rate was comparable.

Arthroscopic management of recurrent synovial chondromatosis of the hip: a case report

Synovial chondromatosis is a rare condition characterized by the chondral proliferation of synovium forming loose bodies which can lead to pain, swelling, and decreased range of movement of the affected joint.

CASE PRESENTATION

Here the authors report a case of eighteen years lady with recurrent hip synovial chondromatosis who was treated previously with hip arthrotomy and loose bodies removal and now she underwent arthroscopic loose bodies removal with partial synovectomy.

CLINICAL DISCUSSION

In comparison to arthrotomy of the hip, arthroscopic management is a minimally invasive surgery that is associated with decreased postoperative pain, earlier improvement in range of motion, a shorter course of rehabilitation, and overall lower morbidity.

CONCLUSION

Thus, the authors recommend arthroscopic removal of the loose bodies and partial synovectomy for the management of synovial chondromatosis of the hip.

Synovial osteochondromatosis mimicking juvenile idiopathic arthritis in an adolescent: a case-based review

Synovial osteochondromatosis is an extremely rare benign condition in children and adolescents that have joint pain as a presenting manifestation. It is usually monoarticular with the knee as the most common affected joint. In this article, we describe the case of a female adolescent suffering from debilitating chronic right knee pain initially mimicking juvenile idiopathic arthritis, who was subsequently diagnosed with primary synovial osteochondromatosis. We present a review of synovial osteochondromatosis focusing on the clinical manifestations, radiographic features, histopathologic findings, and treatment, with a summarized review of pediatric patients with initial musculoskeletal presentations who were ultimately diagnosed as synovial osteochondromatosis. Although synovial osteochondromatosis is rare in children and adolescents, this condition should be included in the differential diagnosis of joint pain and may mimic juvenile idiopathic arthritis. Appropriate diagnostic radiography, including both plain radiography and magnetic resonance imaging, is necessary to accurately diagnose this condition. We also emphasize the importance of a multidisciplinary team approach to managing patients with synovial osteochondromatosis.

Clinical Outcomes after Arthroscopic Treatment of Synovial Chondromatosis in the Hip

PURPOSE

Evaluate the clinical outcomes after arthroscopic treatment of synovial chondromatosis (SC) of the hip.

MATERIALS AND METHODS

We evaluated patients who underwent arthroscopic management for SC of the hip from November 2008 to March 2017. Radiographic evaluation was made before and after surgery. The modified Harris Hip Score (mHHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), visual analogue scale (VAS) score, and patient self-reported satisfaction were collected and analyzed before and after surgery. Complications and recurrence that occurred after surgery were recorded.

RESULTS

Forty-one patients (27 men and 14 women) were the study cohort. The mHHS improved from 67.0 to 83.7, HOOS-Symptoms improved from 78.8 to 93.3, HOOS-Pain improved from 80.9 to 93.6, HOOS-Activity Limitations-Daily Living improved from 84.5 to 95.1, HOOS-Sport improved from 50.3 to 80.6, and HOOS-Quality of Life improved from 62.2 to 86.7. VAS scores decreased from 3.9 to 1.1. All results demonstrated significant improvement (P < 0.05). Thirty-three (80.5%) patients thought the outcome of surgery was "excellent," 7 (17.0%) thought it was "good," 1 (2.4%) thought it was "fair," and no one thought it was "poor". Two patients underwent revision surgery.

CONCLUSION

Hip arthroscopy for SC treatment of the hip showed good clinical results, good satisfaction from patients, and low recurrent prevalence.

Surgical Treatment of Femoroacetabular Impingement: Minimum 10-Year Outcome and Risk Factors for Failure

Femoroacetabular impingement (FAI) is a well-known cause of hip pain and dysfunction in young adults. Surgical treatment has been widely popularized during the past decade. However, most reported results have been limited to short-term and intermediate-term follow-up. The long-term success rate and risk factors for failure are largely unknown. This study aimed to report the long-term (minimum, 10 years) clinical outcomes of surgical treatment of FAI and to describe the clinical and radiographic parameters associated with the failure of treatment involving femoroacetabular osteoplasty (FAO) and labral repair.

Surgical hip dislocation for treatment of synovial chondromatosis of the hip

PURPOSE

In the present study, we aimed to evaluate the clinical outcomes of surgical hip dislocation in patients with synovial chondromatosis (SC) of the hip.

METHODS

Seven patients with primary SC of the hip treated with open synovectomy and removal of loose bodies by surgical hip dislocation from 2016 to 2019 were retrospectively reviewed. All patients had numerous and widespread loose bodies based on pre-operative images, including routine radiographs, CT, and MRI. The visual analog scale (VAS) score and Harris hip score (HHS) were collected and analyzed before and after surgery. The post-operative radiographs were reviewed to evaluate disease recurrence and osteoarthritis progression.

RESULTS

The mean operative time was 61 minutes (range, 42-75 min). An average of 33 loose bodies in each patient (range, 16-67) was removed, and extra-articular pathology was found in one patient. Patients were followed up for a mean duration of 30 months (range, 18-42 months). The average VAS scores were decreased from 3.7 (range, 2-6) pre-operatively to 0.9 (range, 0-2) at the last follow-up, and the HHS was improved from 60.1 (range, 50-73) to 90.1 (range, 82-95). All results demonstrated significant improvements (P < 0.05). Post-operative radiographs showed no recurrence, osteoarthritis progression, or osteonecrosis of the femoral head in all hips.

CONCLUSIONS

Surgical hip dislocation was a practical approach for managing both intra-articular and extra-articular pathologic lesions around the hip. It was an effective treatment for SC of the hip with short surgical time, good joint functions, a lower recurrence rate, and few complications.

An active endoscope with small sweep volume that preserves image orientation for arthroscopic surgery

BACKGROUND

Microsurgery is generally performed in narrow spaces with limited movement. Endoscopes that allow for angle changes have been developed using elastic materials, but they require a large bending space. We propose a new endoscope with a small sweep volume for angle changes.

METHODS

We fabricated a prototype with a thumb-operated joystick. The image sensor is attached to the tooltip. The image signal is input to a motor control board which computes inverse kinematics and transforms it into joint angle values. Each axis is positioned according to these values.

RESULTS

The tooltip sweeping volume was 104 mm³ . Surgeons at the Asan Medical Center used our endoscope to obtain images of the biceps tendon and subscapularis joints of a cadaver.

CONCLUSION

Currently, a low-resolution image sensor is attached to endoscope tooltips. In the future, we will develop a high-resolution image module equipped with an ultra-small complementary metal oxide semiconductor sensor.

Arthroscopic treatment of synovial chondromatosis of hip joint

PURPOSE

This retrospective study summarized the clinical, radiographic, and arthroscopic manifestation of synovial chondromatosis (SC) of the hip, along with the post-operative effect to discuss the curative effect of arthroscopic management of hip SC.

METHODS

Twenty-one patients who underwent arthroscopic surgery from the same surgeon for hip SC were followed up for an average of 45 months. T-shaped capsulotomy was routinely performed in each case. Visual analog scale, range of motion, modified Harris Hip Score, and International Hip Outcome Tool score were collected preoperatively and at the time of the latest follow-up. All patients' demographics, radiographs, and arthroscopic images were collected to summarize and conclude the similarities and differences of their manifestation.

RESULTS

Large wedged clumps of loose bodies demonstrated distinguishable radiographic, arthroscopic appearance and demanded a different surgical strategy. Postoperative scores were all significantly improved. One case of residual pain and two cases of residual loose bodies with no symptom related were reported at the final follow-up. All but one patient were satisfied with the outcome.

CONCLUSION

Arthroscopy treatment of hip SC with T-shaped capsulotomy has demonstrated a good result in terms of clinical outcome score, recurrence rate, and complication rate. On the basis of this study, we concluded the clinical performance of large wedged clumps of loose bodies of hip SC.

A Rare Benign Tumor With Diagnostic Difficulties: Synovial Chondromatosis

In this article, we present a case of a 47-year-old male patient presenting with an insidious onset of hip pain and loss of range of motion. The patient was initially treated conservatively to no avail. Detailed investigations included magnetic resonance imaging of the left hip which revealed a synovitis. Blood results were unremarkable apart from moderately raised inflammatory markers. Differential diagnoses of both intra- and extra-articular hip pain were ruled out and the patient treated for a preliminary diagnosis of psoriatic arthritis for a total of six months. Persistent pain resulted in a re-visit of the diagnosis and further clinical evaluation. This time, an X-ray of the hip revealed calcification at the joint. A computed tomography followed and revealed synovial thickening and intra-articular calcification. A biopsy was consistent with primary synovial chondromatosis (SC). Open synovectomy was performed approximately one year after the onset of symptoms. This case emphasizes the importance of re-visiting initial evaluations and diagnoses when faced with a difficult case of persistent hip pain so to avoid misdiagnosis and unnecessary pharmacological treatment. In view of its rarity and diagnostic challenges, future work on SC should concentrate on gathering data which can be used to produce a diagnostic algorithm.

Mini-Open Femoroacetabular Osteoplasty: Risk Factors for Failure and Conversion to Hip Arthroplasty

BACKGROUND

Surgical treatment of femoroacetabular impingement (FAI) has been increasing over the past decade with reports of favorable results in alleviating patient symptoms. However, progression of osteoarthritis in these patients may necessitate total hip arthroplasty (THA) for the treatment of unresolved or recurrent hip pain and accompanying disability. Identifying the risk factors for disease progression and treatment failure can help orthopaedic surgeons to select the appropriate patients for joint-preservation procedures and allow more informative discussions.

METHODS

With use of the prospective database of hip-preservation surgery at our institution, 652 patients (324 men and 328 women) with FAI who had undergone femoroacetabular osteoplasty (FAO) between December 2004 and April 2016 were identified. Treatment failure was defined as the need for THA. At the latest follow-up, 68 (9.08%)of 749 hips had undergone THA because of the recurrence of symptoms and the development of osteoarthritis. The groups of patients who had or had not undergone conversion to THA were compared with respect to age, sex, body mass index (BMI), surgeon experience, duration of preoperative symptoms, preoperative and postoperative alpha angles, radiographic parameters of hip dysplasia, a perioperative chondral lesion, labral abnormalities and interventions, acetabular retroversion, and severity of osteoarthritis (Tönnis grade).

RESULTS

The mean age (and standard deviation) at the time of the index FAO was 41.9 ± 10.5 years for patients who had had a failure of FAO, compared with 33.4 ± 11.1 years for those who had not. Risk factors for treatment failure included a longer mean symptomatic period before the FAO procedure, older age, higher mean BMI, the presence of hip dysplasia, acetabular retroversion, higher preoperative alpha angle, a full-thickness acetabular chondral lesion, Tönnis grade-1 and 2 osteoarthritis, labral hypertrophy, and total labral resection during FAO. The rate of failure was related to the experience of the surgeon, with fewer failures occurring in the later years of surgery as compared with the earlier years.

CONCLUSIONS

The present study identified a number of variables that influence the outcome of FAO. Surgeons performing hip-preservation procedures should be aware of these risk factors for failure, and a more cautious approach is recommended for patients with these risk factors.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

"False Patellar Duplication" Originated from Synovial Osteochondromatosis in Knee Joint: A Rare Case Report

BACKGROUND:

“False patellar duplication” is a situation where there are two pieces in the position of a knee-joint like patella. It can derive from cartilage tumors, soft tissue tumors, or gout tumors, or due to the heterotopic ossification, forming a sub patella in the knee joint.

CASE REPORT:

A woman, 57 years old, healthy history, she has hospitalized for right knee joint pain since 2 years. Diagnosis: the synovial osteochondromatosis of the right knee. We decided to conduct and arthroscopy and removal. After 18 months surgery, the patient knee joint is currently good, range of motion (ROM) (-10)°- 0°-160°, Lysholm Knee Scoring Scale 85/100 point.

CONCLUSION

This is the second case in the world and the first case in Vietnam. This is an experience in the process of diagnosis, arthroscopic treatment and differentiation from the “double patellae” status.

Usefulness of MR Arthrography of the Hip with and without leg Traction in Detection of Intra-articular Bodies

RATIONALE AND OBJECTIVE

Although intra-articular bodies are a classic indication for MR arthrography and surgical removal, diagnostic studies are currently sparse. To assess the diagnostic performance of MR arthrography with and without leg traction in detection of intra-articular bodies in the hip joint.

MATERIAL AND METHODS

The institutional hip arthroscopy data base (2009-2016: 631 hips) was retrospectively reviewed. Inclusion criteria were hips with and without intra-articular bodies and direct MR arthrography performed with and without leg traction. Twenty-one hips with intra-articular bodies constituted the "disease-positive" group. Seventy-nine randomly selected hips without intra-articular bodies constituted the "disease-negative" group. Images were reviewed independently for presence of intra-articular bodies by two blinded readers. Overall diagnosis and location of intra-articular bodies was recorded (peripheral or central). Arthroscopy served as goldstandard for diagnosis and location of intra-articular bodies. Diagnostic performance and kappa statistics of traction MR arthrography with and without traction were calculated.

RESULTS

For both readers sensitivity/specificity of traction MR arthrography was 86%-95% respectively 90%-91% for overall diagnosis of intra-articular bodies and was 81%-86% respectively 90%-92%for MR arthrogrpahy without traction. For central intra-articular bodies sensitivity was higher for both readers with traction (79%-89%) than without traction (74% each).

CONCLUSION

MR arthrography with and without traction of the hip is highly accurate in identifying central and peripheral intra-articular bodies. Application of traction was further useful for visualization of centrally located intra-articular bodies.

Synovial chondromatosis of the hip, a case report and literature review

A case of giant synovial chondromatosis of the hip with extra-articular localisation in the ileopectineal bursa is presented and the literature concerning this condition is reviewed. Synovial chondromatosis is a rare condition of unknown aetiology. A literature search was performed to identify studies describing outcome after surgical treatment of synovial chondromatosis of the hip. Thirteen studies including two hundred-ninety patients could be included. Mean follow-up was fifty-six months. Seven out of two hundred-ninety developed a complication after surgical resection of the lesion. Recurrence rate of synovial chondromatosis is about 19%. Malignant transformation of synovial chondromatosis to chondrosarcoma is extremely rare. No wound infections were reported and avascular necrosis of the femoral head occurred in one patient who was treated with dislocation of the hip during surgery. After resection of synovial chondromatosis excellent functional outcome can be expected.

Remaining Loose Bodies after Arthroscopic Surgery Including Extensive Capsulectomy for Synovial Chondromatosis of the Hip

Background

The purpose of our study was to evaluate the usefulness of hip arthroscopy including extensive capsulectomy for synovial chondromatosis of the hip.

Methods

From 2008 to 2016, 13 patients with synovial chondromatosis of the hip were treated with arthroscopic removal of loose bodies and synovectomy using three arthroscopic portals. An extensive capsulectomy was performed to allow the remaining loose bodies to be out of the extracapsular space, and the excised capsule was not repaired. All patients were assessed by clinical scores and the radiographs were reviewed to determine whether the remaining loose bodies disappeared at the last follow-up.

Results

Eight men and two women were followed up for a minimum of 1 year (mean, 3.8 years; range, 1 to 6.8 years) after hip arthroscopy. Clinical outcomes such as modified Harris hip score, University of California Los Angeles score, and Western Ontario and McMaster Universities Osteoarthritis Index score improved at the last follow-up. Although seven hips had remaining loose bodies after arthroscopic surgery, the remaining loose bodies disappeared in five hips (71.4%) at the last follow-up.

Conclusions

Arthroscopic surgery was useful to treat synovial chondromatosis of the hip. In spite of limited removal of loose bodies, arthroscopic procedures including extensive capsulectomy could be effective for the treatment of synovial chondromatosis of the hip.

Synovial Chondromatosis

Synovial chondromatosis is a rare, benign condition of unknown etiology in which the synovium undergoes metaplasia leading to cartilaginous nodules that ultimately break free, mineralize, and even ossify. The most commonly involved joint is the knee. Patients may be asymptomatic or may present with pain, swelling, and limited range of motion. Plain radiographs can be diagnostic and mineralized nodules are pathognomonic. Recommended treatment involves arthroscopic or open removal of loose bodies with or without a synovectomy to prevent further articular and periarticular destruction and to relieve symptoms.

Primary Synovial Osteochondromatosis of the Hip Joint Treated with Arthroscopic-assisted Mini-open Surgery-Two Case Reports

Introduction:

Primary synovial osteochondromatosis of the hip joint is a rare condition. It is characterized by the presence of multiple intra-articular loose bodies and can result in mechanical symptoms, even causing degenerative change. Surgical treatment is indicated for synovial osteochondromatosis of the hip joint. However, the optimal approaches for successful surgical management are still controversial.

Case Report:

We report two cases with primary synovial osteochondromatosis of the hip joint where arthroscopic-assisted mini-open surgical treatmentwas performed. The posterior approach was used, and a minimal arthrotomy was performed with preservation of bloody supplement of thefemoral head. With the assistance of an arthroscope, synovectomy, debridement, and loose body removal were completed without dislocating the femoral head. The follow-up duration was 5years and 2.5 years, respectively. There were no perioperative or post-operative complications. At the latest follow-up, the patients remain symptom free with no radiographic evidence of recurrence.

Conclusions:

Our arthroscopic-assisted mini-open method could achieve the goals of extensive synovectomy, debridement, and loose body removal, thus reducing the recurrence rate. This method avoids dislocation of the femoral head, thus reducing the occurrence of surgical complications.

Long-Term Outcome of Hip Arthroplasty in the Setting of Synovial Chondromatosis

BACKGROUND

Synovial chondromatosis (SC) is a rare disease involving cartilaginous metaplasia of synovial tissue. Treatment via synovectomy and loose body removal alone results in elevated recurrence rates, with up to 1 in 5 patients requiring conversion to a hip arthroplasty. The purpose of this study is to investigate outcomes of hip arthroplasty in the setting of SC, focusing on (1) disease-specific survival, (2) implant survivorship and complications, and (3) clinical outcomes.

METHODS

We identified 26 patients with histologically confirmed SC who underwent hip arthroplasty between 1970 and 2015. Mean follow-up and patient age were 10 years (range 2-35) and 55 years (range 26-82), respectively. At the time of arthroplasty, 21 (81%) patients had "active" disease and underwent synovectomy. No constrained acetabular components were used. Six patients (23%) had a preoperative flexion contracture.

RESULTS

The 15-year disease-free survival was 89%. Recurrence occurred in 3 patients at a mean of 0.8 years (range 0.03-1.2) postoperatively. Thirteen patients (50%) sustained a complication [most commonly aseptic loosening (n = 3, 12%)] and 7 required revision surgery. The 10-year and 15-year revision-free survival was 82% and 64%, respectively. Mean Harris Hip Score improved significantly from 50 (range 23-85) preoperatively to 82 (range 44-100) postoperatively (P < .001).

CONCLUSION

Arthroplasty with simultaneous synovectomy provides reliable pain relief and excellent disease-specific survival at long-term follow-up; however, revision and complication rates were high.

Reasons for and functional results of repeated hip arthroscopy: A continuous prospective study of 17 revisions out of 295 primary hip arthroscopies at mean 28months' follow-up

INTRODUCTION

The rate of iterative arthroscopy has been increasing over the last decade as the technique has grown. The results of and reasons for these revision procedures, however, are not exactly known. We therefore conducted a prospective study to shed light on: 1) functional results and patient satisfaction following repeated arthroscopy, and 2) the relevant indications.

HYPOTHESIS

Functional scores and patient satisfaction increase following repeated arthroscopy. MATERIALS AND METHOD: A single-center continuous prospective study without control group included patients undergoing repeated hip arthroscopy between September 2010 and September 2014, with a mean 28months' follow-up (median, 23.3months; range, 12-62months). Preoperative and follow-up functional assessment used the modified Harris hip, WOMAC and Christensen (NHAS) questionnaires, and a satisfaction scale. On etiological analysis, repeated arthroscopy was indicated if a cause of recurrent or persistent pain accessible to arthroscopic treatment was identified.

RESULTS

Seventeen patients were included out of 295 primary arthroscopies (5.7%): 9 male, 8 female; median age, 29.6years (range, 16-48years). Indications for primary arthroscopy comprised 13 cases of femoroacetabular impingement, 3 labrum lesions with instability, 1 chondromatosis and 1 case of osteoarthritis. Eleven of the 17 primary lesions showed persistence, including 9 of the 13 cases of femoroacetabular impingement. There were 3 failures in 17 repeated arthroscopies. All functional scores improved, with a gain of 7 points (P<0.06) on modified Harris hip score, 25 points (P<0.0006) on WOMAC score, and 27 points (P<0.001) on NHAS score. Ten of the 17 patients were satisfied or very satisfied with the repeated arthroscopy (59%).

CONCLUSION

Although less good than on primary arthroscopy, functional results on repeated hip arthroscopy were satisfactory in the short term. The main reason for repeated arthroscopy was persistence of initial abnormality due to insufficient treatment.

Synovial Chondromatosis: A Rare Differential Diagnosis of Hip Pain in a Child

Introduction:

Primary synovial chondromatosis (SC) is a disease of the synovium occurring in the third to fifth decade of life with the peak incidence in the fifth decade and commonly involves the knee in 50% cases. The diagnosis of SC is primarily radiological and intraoperative. Primary SC of the hip is rare, and their prevalence is not known.

Case Report:

A 7-year-old female child presented with pain and limp left hip for 6 weeks. She had a stiff hip gait. Clinical examination revealed a fixed abduction, flexion deformity, and restricted internal rotation with apparent lengthening of 2 cm. The ultrasonography revealed synovial effusion with synovial deposits. Magnetic resonance imaging revealed features of tuberculous synovitis, inflammatory synovitis, or a rare possibility of SC. Arthrotomy was performed following failed hip aspiration. Multiple chondral loose bodies were noted on incision of capsule. Partial synovectomy was also performed. The synovium histopathology revealed multiple synovial chondral inclusions. A final diagnosis of SC was made.

Conclusion:

We report this case of primary SC, 7-year-old female patient with symptoms of hip pain, limp, and fixed deformities restricting hip function as a first of its kind in the mentioned age group. Hence, although rare SC may be considered as one of the differential diagnosis in hip symptoms in children <10 years of age.

A systematic literature review of synovial chondromatosis and pigmented villonodular synovitis of the hip

OBJECTIVES

Benign synovial diseases of the hip including Synovial Chondromatosis (SC) and Pigmented Villonodular Synovitis (PVNS) are devastating diseases. Initially, patients present with hip pain unrelieved by conservative measures. The diagnosis of PVNS and SC are often delayed, leading to progression of joint damage. The purpose of this review is to present the latest on the diagnosis, management, and prognosis of SC and PVNS of the hip.

METHODS

An extensive systematic search of MEDLINE and PUBMED Databases was performed. Data parameters were set from 2005 to present day with set inclusion criteria. Systematic reviews were excluded.

RESULTS

427 abstracts were identified, with 12 articles meeting all inclusion criteria. Eight studies focused on SC, and 5 on PVNS. 233 patients with SC of the hip and 98 patients with PVNS of the hip were identified, a total of 331 patients.

DISCUSSION

Benign Synovial disorders of the hip are rare. In patients with chronic hip pain secondary to benign synovial disorders, early diagnosis and surgical intervention demonstrate good outcomes, and patients may benefit due to prevention of morbidity from further joint destruction. There is no clear consensus between higher successes through open versus arthroscopic surgical debridement. In the final phase of benign synovial disorders of the hip, THA of different types based on the patient's age should be considered.

A Novel Complication of the Dall-Miles Cable Grip System Mimicking Recurrent Synovial Chondromatosis: A Case Report and Review of the Literature

CASE

A 25-year-old man with synovial chondromatosis of the hip was treated with a synovectomy through a transtrochanteric approach; the repair was made with use of a Dall-Miles cable. Approximately 13 years later, the patient returned with a massive bursal reaction and a cyst containing "rice bodies." Although the physical examination and imaging were suggestive of recurrent synovial chondromatosis, the bursal reaction actually represented a novel complication of the Dall-Miles system.

CONCLUSION

When a patient who has had prior orthopaedic instrumentation presents with pain and imaging that demonstrates formation of a bursal cyst, a cyst containing rice bodies secondary to bursal irritation by the implant should be considered.

Anesthesia for hip arthroscopy: a narrative review

PURPOSE

Hip arthroscopy is a minimally invasive surgical procedure indicated for the treatment of specific hip disorders. In this narrative review, we aim to examine the key components in providing anesthesia for this procedure.

SOURCE

MEDLINE(®), PubMed, and EMBASE™ databases were searched for peer-reviewed articles discussing the anesthetic management of patients undergoing hip arthroscopy.

PRINCIPAL FINDINGS

The primary anesthetic regimen used for hip arthroscopy should balance patient factors, preferences of the surgeon, and the demands of the procedure itself. Both general and neuraxial anesthetic techniques are well suited for this mostly ambulatory surgical procedure. There is a lack of current literature specifically comparing the benefits and risks of the two techniques in this setting. Postoperative pain management consists mainly of intravenous and oral opioids; however, a variety of regional anesthesia techniques, such as lumbar plexus block and fascia iliaca block, can be performed pre- or postoperatively. Overall, hip arthroscopy is safe, although positioning-related difficulties, extravasation of irrigation fluid, hypothermia, infections, and thromboembolic events are potential perioperative complications that warrant specific monitoring and prompt treatment.

CONCLUSIONS

Until now, the anesthetic technique for hip arthroscopy has not been well studied. Thus, increasing emphasis should be directed towards examining relevant clinical outcomes that can better inform evidence-based decision-making in the anesthetic management of hip arthroscopy patients. In the meantime, awareness of potential complications and vigilant monitoring are paramount in providing safe anesthetic care for patients undergoing hip arthroscopy.

The use of hip arthroscopy in the management of the pediatric hip

Arthroscopy of the pediatric hip began in 1977 with a publication by Gross. Interest was relatively slow to develop in the 1980s and 1990s. Coupled with the success of hip arthroscopy in the adult, interest heightened in applying the procedure to a variety of pediatric hip disorders, given that the alternative was an open surgical hip dislocation. The success of this initial group of pediatric hip arthroscopist's has further expanded the application of hip arthroscopy as the primary or adjunct procedure for the management of intra-articular problems of the pediatric hip.

A Comparison of Supine and Lateral Decubitus Positions for Hip Arthroscopy: A Systematic Review of Outcomes and Complications

PURPOSE

This systematic review examines outcomes and risk profiles of the hip arthroscopy in the supine versus lateral decubitus positions to elucidate any superiority of one approach over the other.

METHODS

Three databases (Embase, PubMed, and Medline) were searched for studies that addressed hip arthroscopy performed in either position, and were subsequently screened by two reviewers with data abstracted in duplicate.

RESULTS

Similar outcomes were observed. Supine studies showed a greater mean postoperative improvement for modified Harris hip score (33.74), visual analog scale (-3.99), nonarthritic hip score (29.61), Harris hip score (35.73), and hip outcome score (31.4). Lateral decubitus studies showed greater improvement using the Western Ontario and McMaster University Osteoarthritis (14.76) score. Supine studies reported more neuropraxic injuries (2.06% v 0.47%), labral penetration (0.65% v 0%), and heterotopic ossification (0.21% v 0%). Lateral decubitus studies reported more fluid extravasation (0.21% v 0.05%) and missed loose bodies (0.08% v 0.01%). Similar rates of revision (1.8% lateral, 1.4% supine) and conversion to open procedures (2.6% in lateral, 2.0% in supine) were also identified.

CONCLUSIONS

Because of quality of evidence, direct comparisons are currently limited; however, the supine position is associated with more neuropraxic injuries, labral penetration, and heterotopic ossification, whereas lateral decubitus has increased risk of fluid extravasation and missed loose bodies. At this time, no evidence exists to establish superiority of one position.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2013

Introduction

Hip arthroscopy is increasingly adopted for the treatment of intra-articular and extra-articular pathologies. Studies from USA demonstrate a 365% increase in the number of procedures performed between 2004 and 2009 and 250% increase between 2007 and 2011. There is limited evidence of long-term efficacy for this procedure and hip arthroscopy is not universally funded across England. The aim of this study is to describe temporal trends in the adoption of hip arthroscopy in England between 2002 and 2013 and to forecast trends for the next 10 years.

Methods

A search of the Hospital Episodes Database was performed for all codes describing arthroscopic hip procedures with patient age, sex and area of residence.

Results

11 329 hip arthroscopies were performed in National Health Service hospitals in England between 2002 and 2013. The number of hip arthroscopies performed increased by 727% (p<0.0001) during this period and is forecast to increase by 1388% in 2023. Females represent 60% of all patients undergoing hip arthroscopy (p<0.001). Median age category is 40–44 for females and 35–39 for males and average age decreased during the study period (p<0.0001). There is significant regional variation in procedure incidence. In the final year of this study the highest incidence was in the Southwest (8.63/100 000 population) and lowest in East Midlands (1.29/100 000 population).

Conclusions

The increase in number of hip arthroscopies performed in England reflects trends in USA and continued increases are forecast. Evidence from robust clinical trials is required to justify the increasing number of procedures performed and regional variation suggests potential inequality in the provision of this intervention.

Surgical Treatment of Synovial Osteochondromatosis of the Hip Using a Modified-Hardinge Approach with a Z-Shaped Capsular Incision

Synovial osteochondromatosis of the hip is a rare condition, and the surgical treatment approach for this condition requires complete removal of loose bodies combined with synovectomy. While these, procedures are generally accepted as the optimal treatment method, this is still controversial topic. Recent studies have reported that open surgical procedures remain acceptable for synovial osteochondromatosis of the hip. These procedures include the dislocation of the femoral head, and complications such as femoral head necrosis and bursitis or great trochanter non-union due to trochanteric osteotomy have been reported. The present study reports a modified technique for surgical dislocation through a Z-shaped capsular incision without trochanteric flip osteotomy for the treatment of synovial osteochondromatosis of the hip.

Hip arthroscopy

Hip arthroscopy is a safe method for treating a variety of pathological conditions that were unknown until a decade ago. Femoroacetabular impingement is the commonest of these pathological conditions and the one with the best results when treated early on. The instruments and surgical technique for hip arthroscopy continue to evolve. New indications for hip arthroscopy has been studied as the ligamentum teres injuries, capsular repair in instabilities, dissection of the sciatic nerve and repair of gluteal muscles tears (injuries to the hip rotator cuff), although still with debatable reproducibility. The complication rate is low, and ever-better results with fewer complications should be expected with the progression of the learning curve.

Arthroscopy provides symptom relief and good functional outcomes in patients with hip synovial chondromatosis

The purpose of this study was to evaluate clinical presentation, associated pathology and clinical outcomes after arthroscopic treatment of hip synovial chondromatosis (SC). A prospective data registry was queried for patients with SC diagnosis from 2005 to 2012. Surgical indications were intra-articular pain after failure of conservative treatment, labral pathology, chondral damage or loose bodies. All patients had femoroacetabular impingement based on radiographic findings. Patient-centered outcomes were collected before and after surgery. Standard hip arthroscopy techniques were used to address associated pathology. Twenty-three patients met the inclusion criteria. Eleven were males. Mean age was 43.7 years. Mean center-edge angle was 33.7 and alpha angle 73. Radiographs were diagnostic in five patients (23.8%). Magnetic resonance imaging identified loose bodies in 14 (66%). Most patients had an uncountable amount of loose bodies in the central and peripheral compartments. The most common associated pathology was a labral tear (100%) and acetabular cartilage injury (85%). All patients had improvement in range of motion. The average Modified Harris Hip score improved from 62 (pre-op) to 84.8 (post-op). Short-Form 12-PCS improved from 41 to 53. Western Ontario and McMaster Osteoarthritis Index improved from 27.1 to 7.2. Median overall satisfaction was 9.5 (out of 10). Hip arthroscopy with thorough removal of loose bodies and subtotal synovectomy, coupled with an aggressive and early rehabilitation program, was effective in ameliorating symptoms associated with from hip SC, yielding high levels of patient satisfaction and functional outcomes, in a 2.5 year follow-up time. Level of evidence: IV (case series)

Hip Arthroscopy for Synovial Chondromatosis: Tips and Tricks

Hip arthroscopy is an important diagnostic and therapeutic tool in the management of synovial chondromatosis. Removal of osteochondral fragments (OCFs) from the central and peripheral compartments is crucial for the relief of mechanical symptoms and subsequent joint destruction. Direct access to the central compartment is often limited because of the ball-and-socket morphology and limitation of traction. We present our surgical technique for removing OCFs and a new method for the removal of a large loose body using a nitinol stone retrieval basket. The technique facilitates removal of difficult-to-access fragments from the central compartment. Moreover, this technique allows removal of far-medial OCFs from the peripheral compartment.

Arthroscopic surgery for synovial chondromatosis of the hip: a systematic review of rates and predisposing factors for recurrence

PURPOSE

Synovial chondromatosis of the hip is a benign condition whereby pain and functional limitations occur due to numerous intra-articular osteochondral fragments produced by a metaplastic synovium. Recurrence not only worsens morbidity but may lead to malignant transformation. With reported recurrence rates as high as 22% by open surgical approaches and given the increasing use of hip arthroscopy for the treatment of synovial chondromatosis, we sought to quantify the recurrence rate after arthroscopy, as well as identify predisposing factors for recurrence.

METHODS

Using predetermined inclusion criteria, 3 electronic databases--Embase, Medline, and PubMed-were searched for relevant articles addressing arthroscopic surgery for synovial chondromatosis of the hip across all available dates up to and including February 16, 2014. A hand search of the reference sections of the included studies was also completed. Article screening was conducted in duplicate. Reviewer agreement statistics and descriptive statistics of the included studies are presented.

RESULTS

From an initial retrieval of 2,542 studies, 14 studies satisfied the criteria for inclusion. A total of 197 patients (age range, 13 to 81 years) underwent hip arthroscopy for removal of intra-articular osteochondral fragments and synovectomy to alleviate both mechanical symptoms and pain. Follow-up periods ranged from 1 to 184 months, with approximately 7.6% of patients (15 of 197) lost to follow-up. The recurrence rate after hip arthroscopy was 7.1% (14 of 197), and the rate of minor complications, such as perineal and pedal neurapraxia, was 1%.

CONCLUSIONS

For synovial chondromatosis of the hip, arthroscopic removal of osteochondral fragments with synovectomy is both safe and effective, with a mean recurrence rate of 7.1%.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Current possibilities for hip arthroplasty

Hip arthroscopy has been popularized over the last decade and, with technical advances regarding imaging diagnostics, understanding of the physiopathology or surgical techniques, several applications have been described. Both arthroscopy for intra-articular conditions and endoscopy for extra-articular procedures can be used in diagnosing or treating different conditions. This updated article has the objective of presenting the various current possibilities for hip arthroscopy.

Complications following hip arthroscopy: a systematic review and meta-analysis

PURPOSE

The use of hip arthroscopy to address injuries and conditions about the hip is becoming more widespread. There are several narrative reviews regarding complications of hip arthroscopy but a systematic review is currently lacking. The primary goal of this study is to determine the complication rate associated with hip arthroscopy in the literature.

METHODS

A search of the EMBASE and Ovid Medline databases was performed to identify articles published between 1 January 2000 and 25 November 2011 that reported a complication rate after hip arthroscopy. Appropriate inclusion and exclusion criteria were applied to identify articles, and a meta-analysis was performed to determine an overall complication rate. Complications were divided into major and minor.

RESULTS

A total of 66 papers (n = 6,962 hip arthroscopies) were identified and deemed appropriate for analysis. The overall complication rate was found to be 4.0 % (95 % CI 2.9-5.2 %). Of the 287 complications identified in the literature, 20 were deemed major constituting a rate of 0.3 %.

CONCLUSIONS

Hip arthroscopy appears to be safe. The vast majority of complications are minor in nature. Prospective trials looking at the complications of hip arthroscopy would aid in identifying prognostic factors.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, Level III.

Arthroscopic management of primary synovial chondromatosis of the hip

PURPOSE

We evaluated clinical outcomes after hip arthroscopy in patients with primary synovial chondromatosis (SC).

METHODS

We retrospectively assessed 11 patients who underwent hip arthroscopy for primary SC at a mean follow-up of 22 months (range, 12 to 36 months). Clinical preoperative and postoperative evaluation was performed with the Harris hip score. The preoperative evaluation included plain radiographs and magnetic resonance (MR) scanning to detect number and positioning of intra-articular radiopaque loose bodies. The osteochondral damage was graded using the Kellgren-Lawrence classification. The chondral surfaces of both the acetabulum and femoral head were graded according to the Outerbridge scale.

RESULTS

The clinical score improved postoperatively. There were statistically significant differences between preoperative and postoperative Harris hip scores (P < .05). Outcomes were rated as very satisfactory and satisfactory in 3 and 5 of 11 patients, respectively. The osteochondral damage ranged between stages 1 and 2. No complications related to surgical procedures were observed.

CONCLUSIONS

Hip arthroscopy for the treatment of patients with primary SC showed good clinical results without any complications related to the surgical procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic hip preservation surgery

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.

This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip.

Cite this article: Bone Joint J 2013;95-B:10–19.

Arthroscopic treatment of synovial chondromatosis of the hip

BACKGROUND

Recently, arthroscopic loose body removal and synovectomy have been performed as treatments for synovial chondromatosis of the hip joint. However, to date, no reports have been published on the outcomes of arthroscopic treatments.

HYPOTHESIS

Arthroscopic treatment is effective for synovial chondromatosis of the hip joint and has advantages such as low recurrence rates, faster return to activities of daily life, and few surgical complications.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From June 1996 to July 2008, 24 patients with synovial chondromatosis of the hip who were followed up after arthroscopic removal of loose bodies and synovectomy were evaluated. The common arthroscopic portals were the anterior, anterolateral, and posterolateral portals. In some cases, we applied a medial portal for removal of loose bodies in the posteromedial pouch. Preoperative and postoperative assessments were made through simple radiographs, 3-dimensional computed tomography, magnetic resonance imaging, visual analog scale (VAS) for pain, range of motion of the joint, Harris Hip Score, and Merle D'Aubigné and Postel score.

RESULTS

Postoperative mean follow-up period was 41 months. There were no major complications. Patients were able to walk weightbearing on average 2 days after surgery and were discharged in an average of 3.5 days (range, 3-5 days) after surgery. In postoperative radiological imaging, 4 patients showed progression of joint osteoarthritis, and 1 of them underwent total hip arthroplasty. The VAS score before surgery was 8.1 ± 1.3 and after surgery was 3.1 ± 1.4. Range of motion of the hip joint before surgery was increased after surgery, except in 1 patient who required a third operation. Harris Hip Score before surgery was an average of 39 ± 6.9 and improved to an average of 82 ± 10.2 after surgery. Eighteen patients (75%) had good or excellent outcomes. Symptomatic disease recurred in 4 patients (16.7%), and 1 of these 4 patients showed a subsequent recurrence.

CONCLUSION

The treatment of synovial chondromatosis of the hip using arthroscopic loose body removal and synovectomy is relatively successful, and rehabilitation of patients is fast, therefore making it an effective treatment with satisfactory postsurgical results. However, a technical limitation of arthroscopy is the difficulty in approaching the posterolateral and posteromedial areas of the peripheral compartment.

[Hip arthroscopy - indications and limits]

Through continuous improvement and advancement of technology over the last 10 years, hip arthroscopy has developed into a standard orthopedic procedure and this has greatly expanded the range of indications. The main indications for hip arthroscopy include any disorder of the synovial membrane, damage to the labrum acetabulare, lesions of the ligament of the head of the femur, loose bodies, degenerative and traumatic cartilage lesions and especially disorders of the joint mechanism caused by femoroacetabular impingement. Increasingly, endoscopic procedures additionally allow the treatment of periarticular pathologies. Hip arthroscopy is limited in particular due to the difficult anatomy, a large distance from the skin to joint cavity and the problematic visualization of the posteromedial joint area. Furthermore, a time-limited distraction of the joint must be considered in the choice of therapy.

Hip arthroscopy: evolution, current practice and future developments

Arthroscopic examination and treatment is an ever-increasing part of modern orthopaedic practice in this age of minimally invasive surgery. Arthroscopic procedures have been widespread in surgery of the knee and the shoulder for many years; however, the hip until relatively recently, has been largely neglected. Even now hip arthroscopy is not widely available; this may be due to the complexity of the procedure, the requirement of specialist equipment and a reportedly long learning curve. On the other hand, it has gone through a period of rapid growth over the last decade and is being performed in large numbers routinely in some centres around the world. Hip arthroscopy now provides excellent visualisation of not only the articular surfaces of the hip joint but also of the peritrochanteric or extra-articular space around the hip. Pathology of both the femoral head and the acetabulum along with the soft tissues of the hip, namely the ligamentum teres, the acetabular labrum, the synovial folds and synovium, is readily diagnosed. Modern techniques provide therapeutic options for a myriad of conditions and allow modulation of pathological processes early. Additionally hip arthroscopy is a relatively safe procedure with few complications and contraindications. However, the key to good outcomes is in the careful selection of patients and meticulous surgical technique. The aim of this review is to bring the reader up to date with an overview of the evolution of arthroscopy of the hip, review the current practice and explore possible future developments.

Efficacy of hip arthroscopy in the management of synovial chondromatosis

BACKGROUND

Synovial chondromatosis can result in intra-articular loose bodies. Open arthrotomy has been the conventional treatment for this condition in the hip. Hip arthroscopy, however, is a minimally invasive approach and avoids potential problems with open arthrotomy.

PURPOSE

This series was described to evaluate the role of arthroscopy in treatment and outcome of synovial chondromatosis of the hip at early to intermediate follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-nine patients had arthroscopic treatment for synovial chondromatosis of the hip. All loose bodies were intracapsular and smaller than 10 mm. Radiographs of the painful hip, computed tomography (CT), and gadolinium-enhanced magnetic resonance imaging (MRI) were obtained preoperatively. Intraoperatively, loose bodies were removed, and partial synovectomy, partial labrectomy, chondroplasty, and microfracture were done as needed.

RESULTS

There were 14 women and 15 men (mean age, 41 years; mean duration of symptoms, 52 months). All patients had hip pain and 63% reported mechanical hip symptoms. Twenty-three patients were followed for at least 12 months (mean, 64 months). Loose bodies could be seen in the imaging studies of 52% of patients: 8 on radiographs and 7 with CT or gadolinium-enhanced MRI. At surgery, 23 of the 29 (79%) patients had torn labra and femoral head changes. There were an average of 35 loose bodies per patient. Twenty-five of the 29 (86%) had acetabular chondral findings. Five of the 29 patients (17%) eventually underwent total hip reconstruction surgery at a mean of 52 months; 5 of these patients had grade III/IV lesions at the time of arthroscopy. Eleven of the 23 patients (48%) had good to excellent outcomes at an average of 60 months. Recurrent symptoms were seen in 7 patients, and revision arthroscopy was done for 1 patient at 1-year follow-up, 2 patients at 4 years, 1 at 5 years, and 1 at 7-year follow-up. Complications included transient perineal and pedal paresthesia in 2 patients.

CONCLUSION

Patients with synovial chondromatosis with hip central compartment loose bodies that were less than 10 mm benefited from hip arthroscopy. Imaging studies alone failed to establish the diagnosis in 14 of 29 patients (48%). Diagnosis was made by direct visualization via arthroscopy. For patients with grade I/II cartilage change, early diagnosis and treatment via arthroscopy helped. It is a valid and effective treatment at early to intermediate follow-up.

What factors influence long-term survivorship after hip arthroscopy?

BACKGROUND

Hip arthroscopy is an evolving procedure. One small study suggested that a low modified Harris hip score and arthritis at the time of surgery were predictors of poor prognosis.

QUESTIONS/PURPOSES

We therefore intended to confirm those findings with a large patient cohort to (1) determine the long-term nonarthritic hip score; (2) determine survivorship; (3) identify risk factors that increase the likelihood of THA; and (4) use those factors to create a usable risk assessment algorithm.

PATIENTS AND METHODS

We retrospectively reviewed 324 patients (340 hips) who underwent arthroscopy for pain and/or catching. Of these, 106 patients (111 hips or 33%) had a minimum followup of 10 years (mean, 13 years; range, 10-20 years). The average age was 39 years (± 13) with 47 men and 59 women. We recorded patient age, gender, acetabular and femoral Outerbridge grade at surgery, and the presence of a labral tear. Followup consisted of a nonarthritic hip score or the date of a subsequent THA. We determined survivorship with the end point of THA for the acetabular and femoral Outerbridge grades.

RESULTS

Overall survivorship among the 111 hips was 63% at 10 years. The average nonarthritic hip score for non-THA patients was 87.3 (± 12.1). Survivorship was greater for acetabular and femoral Outerbridge grades normal through II. Age at arthroscopy and Outerbridge grades independently predicted eventual THA. Gender and the presence of a labral tear did not influence long-term survivorship.

CONCLUSIONS

The long-term survivorship of labral tears with low-grade cartilage damage indicates hip arthroscopy is reasonable for treating labral tears.

LEVEL OF EVIDENCE

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