Arthroscopy and Microfracture for Osteochondritis Dissecans of the Capitellum in Adolescent Athletes Shows Favorable Return to Sport: A Systematic Review

PURPOSE

To assess return to sport (RTS) in the high-risk young athlete population with capitellar osteochondritis dissecans (OCD) undergoing arthroscopic microfracture (MFX) with or without debridement as well as associated indications, clinical outcomes, radiographic outcomes, and complications.

METHODS

A literature search of all published literature in the English language from PubMed, EMBASE, Scopus, and Cochrane from database inception to April 4, 2022, was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies presented demographics and outcomes for adolescent (<21 years old) patients diagnosed with capitellar OCD who underwent arthroscopic MFX (or drilling/subchondral drilling) or MFX (or drilling/subchondral drilling) with debridement (or loose body removal/chondroplasty). Studies containing multiple surgical techniques that did not distinguish characteristics and outcomes of individual patients by surgical technique were excluded. Additionally, if there was overlap in patient populations between 2 studies, the study with less outcome data was excluded. Extracted data included study properties, patient demographics, lesion characteristics, surgery details, and patient outcomes, including range of motion, outcome scores, and RTS rates. Bias was assessed via the Methodological Index for Non-Randomized Studies (MINORS).

RESULTS

Nine studies of 136 patients and 138 elbows met criteria. Included articles were published between 2005 and 2020 with MINORS scores of 8 to 14 (50% to 88%). The age ranged from 12.7 to 15.7 years with most patients being involved in baseball or gymnastics and a rate of dominant elbow involvement of 55% to 100%. Patient follow-up ranged from 16 to 138 months. All 9 studies reported RTS, ranging from 65% to 100%. Six of these studies categorized the level to which the patient returned, with patients RTS at the same level of competition ranging from 60% to 100%. Six studies reported complications, with a range rate of 0% to 43%; there were a total of 10 complications, 7 of which required reoperations.

CONCLUSIONS

Arthroscopic MFX with or without arthroscopic debridement is a safe and effective treatment for OCD lesions of the capitellum in young, athletic patients. Included studies reported improved clinical, radiographic, and patient-reported outcomes. Aside from 1 study reporting an RTS of 65%, the rate of RTS ranged from 86% to 100%. The percentage of patients returning to sport at the same level of competition ranged from 60% to 100% with a time to RTS ranging from 4.1 to 5 months. A single study reported a complication rate of 43%, while remaining studies reported complication rates between 0% and 19%, with loose bodies being the most common complication requiring reoperation. Follow-up ranged from 16 to 138 months.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Osteochondritis dissecans of the temporomandibular joint: a scoping review

PURPOSE

To perform a scoping review to identify the available evidence regarding osteochondritis dissecans (OCD) of the temporomandibular joint (TMJ).

METHODS

An electronic search of the PubMed, Web of Science and Scopus databases was performed using the following terms: 'Temporomandibular Joint Disorders', 'Osteochondritis Dissecans', 'Joint Loose Bodies' and 'Temporomandibular Joint'. Full-text articles were obtained from the records after applying the inclusion/exclusion criteria.

RESULTS

Ten articles were included in the analysis - six case reports, one case series, one retrospective study, one comparative study and one correlational study - with a total of 39 patients. The most frequently reported clinical presentation involved TMJ pain, locked jaw and articular noises (clicking and crepitus). The imaging methods used to identify OCD were radiographs, tomography, arthrography and magnetic resonance imaging. The reported imaging findings varied widely, but the most frequent were (single or multiple) calcified intra-articular loose bodies, signs of degenerative osseous changes, disc displacements, widening of the joint space and alterations in condylar morphology. Seven articles reported treatments (surgical or conservative), but the treatment outcome was not reported in all of the articles, which makes it difficult to make comparisons.

CONCLUSION

OCD of the TMJ may present various non-specific clinical characteristics, and given the heterogeneous imaging findings, multiplanar images are required for an accurate diagnosis. Finally, the results do not allow recommending a standard treatment for OCD of the TMJ.

Intercruciate trans-septal arthroscopic approach to the posterior compartment of the knee joint

Approach to the posterior compartment of the knee joint and working within it has been made assessable since the trans-septal approach was established. Herein, the authors describe a simple intercruciate trans-septal approach to the posterior compartment of the knee joint. This technique allows a direct visualization to the posterior septum (septum), creating a safer trans-septal portal and easier separation of the septum. The authors have used this approach in conditions such as the posterior cruciate ligament (PCL) reconstruction, PCL avulsion repairs, popliteus tendon reconstruction, posterior compartment synovectomy, hardware removal, loose bodies removal, meniscus ramp lesion repair, and others. No complications such as femoral condyle damage, meniscus damage, or neurovascular bundle injuries has occurred with this approach.

Primary Distal Interphalangeal Joint Tenosynovial Chondromatosis of the Small Finger: A Case Report With Literature Review

Primary synovial chondromatosis is a rare, benign proliferative disease of the joint synovium, tenosynovium, or bursal lining, in which cartilage metaplasia leads to the development of multiple intra-articular and periarticular loose osteocartilaginous bodies. This disease usually involves larger joints (knee, hip, elbow, and shoulder), but it has also rarely been reported in the hand. Patients with this disease complain of pain, swelling, nodules, and decreased range of motion of the affected joint. Due to its nonspecific symptoms and low prevalence, this disease often goes misdiagnosed, leading to delays in patient treatment. In the literature to date, there are only a few reports of primary synovial chondromatosis. In this case report, we present a patient with a rare case of primary synovial chondromatosis localized to right small finger distal interphalangeal joint.

Temporomandibular joint synovial chondromatosis: An analysis of 7 cases and literature review

OBJECTIVE

To investigate the diagnosis and treatment procedure of synovial chondromatosis (SC) of the temporomandibular joint (TMJ).

METHODS

Clinical features, imaging features, surgical methods, and prognosis of 7 patients with SC of the TMJ were analyzed. We also reviewed and analyzed surgery-relevant literature included in the Pubmed database in the past decade using the search terms "synovial chondromatosis" and "temporomandibular joint", and found 181 cases.

RESULTS

There was no specific difference in the symptoms of SC in the TMJ in different Milgram's stages in our cases and the cases mentioned in the literature. The main symptoms of SC in the TMJ were pain (100%, 7/7; 64.64%, 117/181), limited mouth opening (57.14%, 4/7; 53.59%, 97/181), swelling (14.29%, 1/7; 28.18%, 51/181), crepitus (28.57%, 2/7; 19.34%, 35/181), and clicking (14.29%, 1/7; 9.94%, 18/181) in our cases and cases from literature separately. The imaging features of SC were occupying lesions (including loose bodies or masses) (71.42%, 5/7; 37.57%, 68/181), bone change in condyle or glenoid fossa (1/7, 14.29%; 34.81%, 63/181), effusion (42.86%, 3/7; 20.99%, 38/181), joint space changes (42.86%, 3/7; 11.05%, 20/181) in our cases and cases from literature separately. The surgical procedures seem to depend mainly on the involved structures and the extension of the lesion rather than the Milgram's stage.

CONCLUSIONS

The clinical features of SC in the TMJ are nonspecific and easy to be misdiagnosed. MRI is helpful in the diagnosis of SC in the TMJ. The surgical procedures mainly depend on the involved structures and the extension of the lesion.

Two Cases of Temporomandibular Synovial Chondromatosis Associated with Gli1 Gene Mutation

Synovial chondromatosis (SC) is a rare benign disease involving multifocal generation of ectopic cartilage in the synovial tissue. Herein, we report two cases of SC in the temporomandibular joint: a 38-year-old woman (patient 1) and 39-year-old woman (patient 2). Both patients had trismus, jaw joint noises, and jaw-opening pain in the temporomandibular joint. Cone-beam computed tomography (CT) and magnetic resonance imaging (MRI) in patient 1 showed multiple calcified loose bodies around the right mandibular condyle. In addition, CT and MRI in patient 2 showed multiple calcified loose bodies around the left mandibular condyle and temporal bone perforation. Following establishing a diagnosis of SC, both patients underwent tumor resection via open surgery. In immunohistochemical examinations of the resected tissues, tumor cells showed intense nuclear staining with labeled anti-Gli1 antibody. Gene sequencing revealed that both patients had a homozygous mutation in the Gli1 gene (rs2228226 G>C). In conclusion, we suggest that the Gli1 gene (rs2228226 G>C) may be involved in the etiology of SC.

Indications for Hip Arthroscopy

CONTEXT

Hip arthroscopy is gaining popularity within the field of orthopaedic surgery. The development and innovation of hip-specific arthroscopic instrumentation and improved techniques has resulted in improved access to the hip joint and ability to treat various hip pathologies.

EVIDENCE ACQUISITION

Electronic databases, including PubMed and MEDLINE, were queried for articles relating to hip arthroscopy indications (1930-2017).

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Initially used as a technique for loose body removal, drainage/debridement of septic arthritis, and treatment of pediatric hip disorders, hip arthroscopy is currently used to treat various hip conditions. The recognition of femoroacetabular impingement (FAI) as a source of hip pain in young adults has rapidly expanded hip arthroscopy by applying the principles of osseous correction that were previously described and demonstrated via an open surgical dislocation approach. Hip pathologies can be divided into central compartment, peripheral compartment, peritrochanteric space, and subgluteal space disorders.

CONCLUSION

Although hip arthroscopy is a minimally invasive procedure that may offer decreased morbidity, diminished risk of neurovascular injury, and shorter recovery periods compared with traditional open exposures to the hip, it is important to understand the appropriate patient selection and indications.

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Zusammenfassung. Radiuskopffrakturen sind zwar sehr häufige Verletzungen, heilen meist aber relativ schnell und unkompliziert aus. Mit dieser Häufigkeit und «Einfachheit» geht jedoch eine gewisse Bagatellisierung einher. Aber selbst bei den einfachsten Radiuskopffrakturen liegt in bis zu 18 % der Fälle eine Begleitverletzung der Weichteile vor. Werden diese übersehen und/oder nicht behandelt, können sie schwere Folgeschäden verursachen. In Anbetracht dieser Problematik sollte der klinische Verlauf bei diesen Patienten genau verfolgt werden. Ein Ausbleiben der Schmerzlinderung nach zwei Wochen konservativer Therapie sollte eine weitere Abklärung nach sich ziehen.

Osteochondrosis dissecans of the temporomandibular joint: a case report and a review of literature

A case of a 71-year-old female patient with osteochondrosis dissecans of the right temporomandibular joint is presented. Osteochondrosis dissecans usually occurs at the weight-bearing convex cartilage in all larger joints. It is rarely found in the temporomandibular joint and usually shows one or two loose bodies dislodged from defects which are present on the condylar head. Because of multiple loose bodies and a defect on the temporomandibular fossa, the case presented here is very uncommon.

Multiple Osseous Loose Bodies Associated with Lumbar Isthmic Spondylolisthesis

BACKGROUND

Multiple osseous loose bodies in the lumbar spine have never been reported. We describe a rare surgical case of multiple osseous loose bodies associated with lumbar isthmic spondylolisthesis.

CASE DESCRIPTION

A 74-year-old man who experienced left foot numbness and bilateral gluteal pain was diagnosed with lumbar spondylolisthesis 7 years previously and managed conservatively. He reported recurrence of the left foot numbness 6 months previously, at which time aggressive (rather than conservative) therapy became a consideration. Radiographs of the lumbar spine revealed L5 isthmic spondylolisthesis with dynamic instability at L5/S1. Magnetic resonance imaging of the lumbar spine revealed multiple mass lesions dorsally located in the lumbar canal. Computed tomography myelography demonstrated multiple osseous materials near the isthmic portion at the L5 level where compression of the dural sac by the lesions induced lumbar canal stenosis. The patient underwent posterior decompression surgery that enabled total removal of the osseous lesions. Intraoperative findings revealed osseous lesions located in the fibrocartilage material and no connection of the lytic portion at the L5 level or ligamentum flavum. Postoperative course of the patient was uneventful as his neurological symptoms improved.

CONCLUSIONS

We described the first instance of multiple loose bodies in the spinal canal with lumbar canal stenosis. It is presumed that long standing minor trauma due to dynamic instability with a trend of hyperossification induced secondary synovial osteochondromatosis forming multiple loose bodies.

Treatment of Osteochondritis Dissecans of the Talus in Skeletally Immature Population: A Critical Analysis of the Available Evidence

Juvenile osteochondritis dissecans of the talus (JOCDT) is a subchondral bone alteration and a partially or completely detached osteochondral fragment, affecting skeletally immature patients. A review of the English literature on PubMed was conducted. Conservative treatment was applied in patients up to Berndt-Harty stage III. Surgical indications were conservative management failure and loose bodies. The most performed procedures were drilling, subchondral bone grafting, fragment fixation, or excision. High rate of clinical success were achieved, whereas radiographic results were much lower. None of the surgical options demonstrated to be superior. Future long-term qualitative studies focusing on chondral tissue restoration are needed.

LEVELS OF EVIDENCE

Therapeutic, Level IV.

Extra and Intra-articular Synovial Chondromatosis

Synovial chondromatosis is not so rare intra-articular condition secondary to synovial metaplasia, that affects the knee joint. Extra-articular synovial chondromatosis however is an extremely rare condition that usually involves the synovial sheath or bursa of the foot or hand. We present two cases of synovial chondromatosis, one intra and one extra-articular. The first case was a 25 year old lady who presented with pain, swelling and restricted range of motion of left knee and was found to have an intra-articular synovial chondromatosis which was treated successfully by joint debridement. The second case was that of a 22 year old man who presented with right knee pain and was diagnosed to have an extra-articular synovial chondromatosis of his right medial hamstring tendon sheath, excision of which resulted in complete relief of symptoms.

Ankle surgery: focus on arthroscopy

BACKGROUND

The ankle joint can be affected by several diseases, with clinical presentation varying from mild pain or swelling to inability, becoming in some cases a serious problem in daily life activities. Arthroscopy is a widely performed procedure in orthopedic surgery, due to the low invasivity compared to the more traditional open field surgery. The ankle joint presents anatomical specificities, like small space and tangential view that make arthroscopy more difficult.

METHODS

From 2000 more than 600 ankle arthroscopies were performed at our institution. The treated pathologies were mostly impingement syndrome and osteochondral lesions, and in lower percentage instabilities and ankle fractures.

RESULTS

In the impingement, the AOFAS scores at FU showed an increase compared to scores collected preoperatively, with improvement of symptoms in most of the cases, good or excellent results in 80 % of cases. In ligament injuries, AOFAS score significatively improved at the maximum follow-up. In fractures all patients had an excellent AOFAS score at maximum follow-up, with complete return to their pre-injury activities. In osteochondral injuries, the clinical results showed a progressive improvement over time with  the different performed procedures. Control MRI and bioptic samples showed a good regeneration of the cartilage and bone tissue in the lesion site.

CONCLUSIONS

The encouraging obtained clinical results, in line with the literature, show how the arthroscopic technique, after an adequate learning curve, may represent a precious aid for the orthopedic surgeon and for the patient's outcome.

LEVEL OF EVIDENCE

Case series, Level IV.

Arthroscopically-assisted removal of retained loose bodies in acute acetabular fractures: a modified technique

Arthroscopically-assisted extraction of loose bodies retained in a hip joint after hip dislocation or acetabular fracture in the acute setting remains controversial. This article describes a practical and reproducible arthroscopically assisted modified anterior approach for extracting loose bodies from a hip joint. This approach may be used in the acute dislocation or fracture setting.

[Posterior fixation and fusion for treatment of Os odontoideum complicated by atlantoaxial dislocation]

OBJECTIVE

To summarize the techniques and evaluate the therapeutic effect of posterior fixation and fusion in the treatment of Os odontoideum complicated by atlantoaxial dislocation.

METHODS

From March, 2007 to October, 2010, 10 patients with Os odontoideum (including 6 male and 4 female patients aged from 20 to 65 years, mean 39.8 years) were treated in our hospital. Before and after the operation, the patients underwent X ray, CT and MRI examinations to measure and evaluate the degree of dislocation and neural compression. After preoperative traction for 1-2 weeks, all the 10 patients showed deductible atlantoaxial dislocation. Through a posterior approach, Atlantoaxial pedicle screws fixation were performed in 9 cases, and C2/3 pedicle-Occiput screw fixation was performed in 1 case. All the patients wore cervical collars as external support for 3 months after the operation.

RESULTS

The mean operative time was 3 h in these patients with a mean intraoperative blood loss of 420 ml. The symptoms were relieved after the surgery in all the patients, who showed no neck pain or neurological defects. The patients were followed up for 6 to 52 months (mean 22 months), and bony fusion was observed in all the 10 cases within 6 to 8 months without such complications as internal fixation failure or redislocation of the atlas.

CONCLUSION

Patients with Os odontoideum complicated by atlantoaxial dislocation should undergo surgical stabilization to avoid severe neurological injury. Pedicle screw instrument in the atlas allows restoration of the spinal stability, short-segment fusion, and maximal preservation of the mobility of the neck.

[Efficacies of arthroscopic debridement and olecranon fossa plasty in the treatment of osteoarthritis and posterior elbow impingement]

OBJECTIVE

To evaluate the efficacies of arthroscopic debridement and removal of osteophyma for olecroanon and olecranon fossa plasty for posterior impingement of elbow joint.

METHODS

Between 1999 and 2008, a total of 21 cases were diagnosed with osteoarthritis and posterior elbow impingement. There were 15 males and 6 females. And there were 16 right and 15 left cases. They included volleyball players (n = 7), tennis players (n = 7), golf enthusiasts (n = 4) and fencers (n = 3). The average duration of onset-operation was 3.5 years (range: 2.5 - 8). Arthroscopic exploration revealed synovial hyperplasia hypertrophy, cartilage degeneration and olecranon fossa hyperplasia with deformed olecranon fossa. Debridement and plasty were performed. Loose bodies were removed from elbow joint in 6 patients. Partial resection of posterior olecranon tip was performed and osteophytes or fibrous tissue removed in this area. Dynamic observation showed no posterior elbow impingement.

RESULTS

Postoperative follow-up was conducted in 19 cases and 2 cases became lost to follow-up. The average follow-up period was 25.3 months (range: 18 - 42). All patients were evaluated preoperatively and postoperatively with the Hospital for Special Surgery Elbow Assessment Scale. The outcomes were excellent (n = 12), good (n = 7) and fair (n = 2). Postoperative patients elbow swelling and pain relieve, sports and life function returns to normal, elbow flexion and rotating mobility obviously improved. With the elbow radiological films to measure the range of motion, the average range of motion was 90.5° preoperatively and improved to 130° postoperatively. There was significant improvement in all cases.

CONCLUSION

Posterior elbow impingement is caused by hyperextension trauma and elbow overuse during specific sporting activities. Arthroscopic debridement and olecroanon or olecranon fossa plasty demonstrates excellent results for posterior impingement of elbow joint.

Synovial fringe (plica) of scapho-trapezial joint following trauma

We herein present a case of radial wrist pain following trauma. Magnetic resonance imaging showed a large area of abnormal soft tissue in the scapho-trapezial joint. The patient was treated successfully by complete resection of the soft tissue. The soft tissue was diagnosed to be synovial fringe based on a histological study. Synovial fringe is frequently reported as a cause of knee and elbow pain, however, it is a rare cause of wrist pain at the scapho-trapezial joint.

MRI and arthroscopy correlations of the elbow: a case-based approach

The number of elbow arthroscopies and indications for the procedure have increased significantly since the advent of modern elbow arthroscopy in the 1980s. In addition to the patient history, physical examination, and plain radiography, MRI is an important tool for the clinician in diagnosing several pathologies within and around the elbow. Understanding the pathophysiology and clinical presentation and being familiar with the MRI characteristics of a variety of elbow conditions will assist the physician in making an accurate diagnosis and help guide appropriate treatment.

Delayed intra-articular migration of the IntraFix outer sheath after anterior cruciate ligament reconstruction: a case report

We describe a case of foreign body synovitis caused by delayed intra-articular migration of the outer sheath 5 months after anterior cruciate ligament (ACL) reconstruction with a quadrupled tibialis allograft tendon using the IntraFix device for tibial fixation. The postoperative course was unremarkable. At 5 months after surgery, the patient experienced a sudden catching sensation and a slight pain without any obvious twisting or trauma. At 6 months after surgery, extension deficit was 20°. At arthroscopy, intra-articular migration of the outer sheath from the tibial tunnel and reactive synovitis were observed. The outer sheath in the joint and the inner screw in the tibial tunnel were removed successfully. The ACL graft was well incorporated under good tension. Patient was able to return to her previous level of all daily activities with no further episodes of swelling. To our knowledge, described here is the only case of foreign body synovitis due to intra-articular migration of the unbroken sheath.

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

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

Synovial chondromatosis of the elbow causing a mechanical block to range of motion: a case report and review of the literature

We report a unique case of elbow synovial chondromatosis with sudden onset of severe loss of elbow extension and flexion range of motion caused by mechanical block from deposition of chondral fragments in the olecranon and coronoid fossae, respectively. We performed successful arthroscopic surgical treatment of synovial chondromatosis of the elbow. Arthroscopy examination revealed an acutely evolving synovial chondromatosis. Three-year follow-up indicated that arthroscopic removal of loose bodies and partial synovectomy can yield lasting improvement in motion without disease recurrence.

Elbow arthroscopy: setup, portal placement, and simple procedures

Elbow arthroscopy has become an accepted treatment for numerous elbow conditions, including loose bodies, lateral epicondylitis, contractures, painful osteophytes, synovitis, osteochondritis dissecans, synovial plica, and osteoarthritis. It is absolutely necessary that the treating surgeon have complete knowledge of elbow anatomy. Three options exist for patient positioning: supine, prone, and lateral decubitus. Standard arthroscopic probes, grasping forceps, punches, and motorized shavers and burrs are used in the procedure. Retractors are essential for visualizing, exposing, and protecting nerves. Specially designed capsular biters can be used to develop a plane between the capsule and the surrounding soft tissues to facilitate capsulotomy and capsulectomy. Among elbow arthroscopists, the sequence of portal placement varies; however, there is little variation in the exact location of portal placement because of neurovascular constraints. Loose body removal and extensor carpi radialis brevis release for lateral epicondylitis are common procedures suitable for the beginning arthroscopist. For beginning and advanced procedures, the surgeon's skill and competence must be at a level consistent with the procedure to avoid complications.

Arthroscopic loose body removal after hip fracture dislocation: experiences in 7 cases

OBJECTIVE

The aims of the present study were to describe the technique of hip arthroscopy for osteochondral loose body removal after posterior hip dislocation and report its preliminary results.

MATERIAL AND METHOD

We reported consecutive patients undergoing hip arthroscopy for osteochondral fragment after sustaining fracture-dislocations. Seven patients who sustained traumatic hip dislocation with incarcerated osteochondral were included in this study. All patients had standard AP pelvis x-rays and 3D-CT scans. After closed reduction, all patients underwent hip arthroscopy in which loose bodies were removed and labral pathology debrided.

RESULTS

The mean follow-up was 15.7 months. The average Harris Hip Score was 89.8. No patient developed any of the complications commonly associated with arthrotomy including avascular necrosis, heterotopic ossification, and nerve injury.

CONCLUSION

Arthroscopic treatment of intra-articular loose bodies after hip fracture-dislocations allows excellent visualization of the joint and facilitated straightforward removal of the fragment.

Enlargement of an osseous loose body in the cervical spine with cord compression

BACKGROUND CONTEXT

Loose bodies in the spinal canal are extremely rare, with only two cases reported previously in the literature.

PURPOSE

To report a rare case of an osseous loose body in the cervical spine with radiographic evidence of dramatic enlargement of the loose body in the spinal canal over the course of 9 years.

STUDY DESIGN/SETTING

Case report.

PATIENT SAMPLE

A 50-year-old man presented with progressive numbness and weakness of the upper and lower extremities and swaying gait in 2007. He had a history of temporary incomplete tetraplegia after a fall in 1998. Magnetic resonance imaging revealed enlargement of the posterior mass-occupying lesion compressing the cord at C5-C6 over the course of 9 years.

OUTCOME MEASURES

Neurological examination with motor and sensory status.

RESULTS

Posterior decompressive laminectomy was performed. An isolated, smooth-surfaced, bony, hard mass was found between the ligamentum flavum and facet joint and removed. Histological examination demonstrated trabecular bone and peripheral cartilage mixed with fibrous and fibrocartilaginous tissue. Clinical evaluation of the patient 6 months postoperatively showed total resolution of neurological symptoms.

CONCLUSION

We report herein an extremely rare case of an osseous loose body in the spinal canal with cord compression. This report represents the first documented case of growth of a loose body in the spinal canal.

Technique and indications of elbow arthroscopy. A twelve-cases report

AIM

Describe the technique of the elbow arthroscopy and discuss their indications through a series of 12 cases and a review of the literature.

METHODS

We report a retrospective study of a short series of 12 cases of elbow arthroscopy performed on 4 years. The indications of this technique were loose bodies in 7 cases, parcellar displaced fracture of radial head in 3 cases, fracture of coronoid process in one case and osseous impingement in one case.

RESULTS

We have noted no complications and at a mean follow up of 18 months (6 to 40 months) our results were almost satisfactory.

CONCLUSION

Elbow arthroscopy is an effective but delicate technique. Its indications are not frequent. They are dominated by loose bodies.

Capitellar cartilage injuries concomitant with radial head fractures

PURPOSE

To evaluate the incidence and types of capitellar cartilage injuries associated with higher-grade radial head fractures.

METHODS

Fifty-one consecutive patients with operatively treated, unstable, displaced Mason type II to III radial head fractures were identified. Ten of 51 patients had capitellar cartilage injuries concomitant with these fractures. All cartilage injuries were identified at the time of surgery except in 1 patient whose injury was determined via computed tomography. There were 8 men and 2 women with an average age of 33 years (range, 24-39 years). Lesions were seen with direct inspection and recorded by location, size, and thickness.

RESULTS

The incidence of capitellar chondral lesions concomitant with operatively treated Mason type II to III radial head fractures appeared in 10 of 51 patients. The average size was 5 x 5 mm (range, 2 x 2 mm to 10 x 10 mm). Four patients had Mason type II and 6 had Mason type III radial head fractures. The average surface of the cartilage injury was 6 x 7 mm (range, 3 x 6 mm to 10 x 10 mm) for Mason type II fractures and 4 x 4 mm (range, 2 x 2 mm to 5 x 10 mm) for Mason type III fractures. Two Mason type III fractures had full-thickness cartilage lesions, and 4 Mason type III fractures had partial-thickness cartilage lesions. Two Mason type II fractures had full-thickness cartilage lesions and the other 2 had partial-thickness cartilage lesions.

CONCLUSIONS

Capitellar cartilage lesions frequently occurred concomitantly with higher-grade radial head fractures. The incidence of these lesions increased with greater severity of radial head fractures. Low-grade radial head fractures created higher-grade cartilage lesions as the intact radial head can cause more damage to the capitellum. Careful evaluation of the joint should be performed for these subtle injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

[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.

Longitudinal long-term results of surgical treatment in patients with osteochondritis dissecans of the femoral condyles

In a longitudinal study, we performed a second follow-up examination on patients suffering from osteochondritis dissecans at the femoral condyles 10 years after a first follow-up, which had been performed 10 years after surgical treatment. Results (clinical score; radiological signs of OA) were analysed depending on the stage of the epiphyseal plate at the time of surgery, the used surgical procedure was divided into retrograde and anterograde procedures, and removal of loose bodies depending on the stage of the lesion. The analysis clearly exhibited that JOCD patients demonstrated better results than AOCD patients. The clinical score obtained after 10 years improved significantly with time, particularly for JOCD patients. Overall, when a retrograde procedure had been used in cases with an intact cartilage layer clinical results were better than those obtained in patients in whom an anterograde procedure with restoration of the joint surface or simple removal of the loose fragments had been performed. After a mean follow-up of 20 years the mean OA-stage was 0.27 in JOCD patients, whereas in AOCD patients a mean OA-stage of 1.55 was detected. Worst OA-changes were detected in patients in whom acrylic glue had been used for refixation of the loose bodies.

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.

[Autologous chondrocyte transplantation by the sandwich technique. A salvage procedure for osteochondritis dissecans of the knee]

The case presented is that of a 23-year-old man suffering from osteochonditis dissecans (OCD) of the medial femoral condyle, in whom a free piece of cartilage had separated off and there was a large osteochondral defect despite numerous operations. After refixation of the fragment failed, an autologous chondrocyte transplantation (ACT) was performed using the sandwich technique. Three years after the operation the patient is very satisfied with the result. The radiological findings show stable repair of the bony and cartilaginous defect area. This case report shows that ACT is a valid method for the treatment of large osteochondral defects even after several previous failed operations. The low donor site morbidity is an important advantage over other methods, such as transplantation of osteochondral plugs.

A case of recurrence of synovial chondromatosis of the temporomandibular joint

This is a case study of a patient with recurrent synovial chondromatosis. It shows some relevant images. It also provides possibilities for why this patient may have had a recurrence and how this was managed.

Arthroscopic treatment for synovial chondromatosis of the subacromial bursa: a case report

Synovial chondromatosis of the subacromial bursa has been reported rarely. To the best of our knowledge, there was no case report of arthroscopic treatment for synovial chondromatosis of the subacromial bursa in English literature. The authors present a case of synovial chondromatosis of the subacromial space in a 45-year-old male, which was managed by arthroscopy. This rare condition can be well managed on similar lines as the other joints through arthroscopic surgery.

Synovial chondromatosis of the posterior cruciate ligament managed by a posterior-posterior triangulation technique

Various causes have been reported for cystic lesions arising from the cruciate ligaments. We present a case of synovial chondromatosis that involved the posterior cruciate ligament and was treated by an arthroscopic posterior-posterior triangulation method. We recommend that synovial chondromatosis be considered in the differential diagnosis of cystic lesions of the cruciate ligaments. Lesions involving the posterior aspect of the posterior cruciate ligament, as in the presented case, can be accessed via the standard anterior arthroscopic portals. However, scattered synovial chondromatosis masses located in the posterolateral compartment are difficult to access via anterior portals. We suggest that the arthroscopic posterior-posterior triangulation technique may be useful for the management of such cases.

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.

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.

[Giant bursitis with rice bodies of the shoulder/neck region in a patient with rheumatoid arthritis without joint-connection]

Giant bursitis with rice bodies is an important clinical entity recognized in rheumatoid arthritis. Usually the bursitis is connected to a joint space. In this unusual case of a giant bursitis of the shoulder/neck region, no connection to a joint could be found. The bursitis lays directly on a rib. The clinical and radiological findings are presented and this special case is discussed in comparison to the literature.

Ultrasonographic and arthrographic diagnoses of synovial chondromatosis

Synovial chondromatosis (SC) is rare in the temporomandibular joint (TMJ). Plain radiographs, CT, MRI and arthrography of the TMJ have been used for the diagnosis of SC. The purpose of this paper is to present ultrasonographic and arthrographic diagnoses of a case of SC of the TMJ.

Histologic evaluation of osteochondral loose bodies and repaired tissues after fixation

PURPOSE

The purpose of this study was to evaluate histologic changes in osteochondral loose bodies in the rabbit knee joint and histologic changes in repaired tissue after fixation of osteochondral loose bodies following isolation periods of varying length.

METHODS

We harvested osteochondral fragments from the patellar groove in rabbit knee joints and left them in the lateral gutters of the joints for periods of varying duration to create osteochondral loose bodies. We then evaluated histologic and immunohistochemical changes within these loose bodies. Next, we fixed osteochondral loose bodies that had been isolated for various periods within the joints to the osteochondral defect in the patellar groove. Twelve weeks after fixation, repaired tissues were evaluated histologically and immunohistochemically, and results were analyzed according to the varying isolation periods of fragments.

RESULTS

Extracellular matrix and type II collagen expression of osteochondral loose bodies deteriorated with increased duration of fragment isolation periods. A significantly negative correlation was noted between length of isolation periods and histologic grading scores. After osteochondral loose bodies had been fixed, repaired tissues deteriorated significantly in accordance with duration of fragment isolation periods. However, in some cases, even when osteochondral fragments had been isolated for 12 weeks, repaired tissues showed dense extracellular matrix stained by safranin O and abundant type II collagen expression, which indicated regeneration of the cartilage layer.

CONCLUSIONS

Osteochondral loose bodies and repaired tissues deteriorated after they were fixed to osteochondral defects. Although a direct correlation was noted between isolation periods of fragments and time to their deterioration, some osteochondral loose bodies showed regeneration of cartilage after fixation.

CLINICAL RELEVANCE

Clinically, reduction of osteochondral loose bodies should be performed as early as possible, if these can be found. However, even if the fragment seems to be old, fragment fixation is worthy of consideration.

[Osteochondritis dissecans]

Osteochondritis dissecans (OCD) is a disease of unknown etiology, characterized by separation of necrotic bone from its bony bed. While the juvenile form seen in patients with open physes has a 60-90% rate of spontaneous resolution, the adult form has virtually no chance of spontaneous healing. Plain X-rays are sufficient for the diagnosis, and magnetic resonance imaging (MRI) is essential for evaluation of disease progression and/or healing. The clinical correlation of MRI criteria defined in recent years to determine stability of the lesion is high. Juvenile OCD can be treated conservatively if there are no signs of instability on magnetic resonance images. Adult patients or unstable lesions in children should be treated surgically. For stable lesions, arthroscopic antegrade perforation is indicated to increase vascularity and stimulate healing. Unstable or displaced lesions should be treated with debridement, internal fixation, and cancellous bone grafting. Although cannulated metal screws are the most widely used implants for internal fixation, biodegradable implants have also been utilized in recent years. Loose fragments that are too deformed to be internally fixed should be removed and cartilage reconstruction techniques should be employed for the remaining crater. Long-term results of loose body removal alone are unsatisfactory. Modern cartilage restoration techniques are technically demanding due to the large, deep, and unconfined nature of the defect in the femoral condyle.

Arthroscopic loose-body removal in posterior compartment of the knee joint: a technical note

The arthroscopic removal of loose bodies in the knee joints is a relatively common procedure. Quite often intra-articular loose bodies tend to localize at the posterior compartment due to gravity effect. However, it is often technically demanding to find and remove loose bodies located at the posterior compartment of the knee joint arthroscopically. We present the technical aspects of arthroscopic removal of the loose bodies located in the posterior compartment of the knee joint. Loose bodies at posterior compartment were subdivided into six regions in posterior knee compartment with preoperative MRI and arthroscopic findings. Each section needs slight different application of arthroscopic techniques for removal. We retrospectively studied 52 knees in 50 patients who underwent arthroscopic loose-body removal in posterior compartment, in 28 knees, additional posterior trans-septal portal was needed for removal of loose bodies. With the help of trans-septal portal, we have successfully removed the loose bodies even from the most difficult locations in posterior compartment.