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JBJS Essential Surgical Techniques Mar 2016Knee arthroscopy is the most commonly performed orthopaedic procedure in the United States. Indications have grown exponentially since the procedure was first...
Knee arthroscopy is the most commonly performed orthopaedic procedure in the United States. Indications have grown exponentially since the procedure was first popularized by Watanabe and Jackson. Treatment of meniscal tears is the most common reason for knee arthroscopy, with approximately 700,000 arthroscopic partial meniscectomies performed annually. Other indications include assistance for cruciate ligament reconstruction, osteochondral lesions, removal of loose bodies, synovectomy, and septic arthritis. Arthroscopy is accomplished with the use of two small incisions on either side of the patella at the anterior aspect of the knee. An arthroscope is inserted through one incision and used to view the image on a monitor, while the second incision is employed for instrumentation. An examination with the patient under anesthesia should always be performed prior to the initiation of the procedure. The patient is positioned with the knee flexed and a lateral post secured to the side of the bed. Standard anteromedial and anterolateral portals are made, and an arthroscope is introduced through the anterolateral portal. Diagnostic arthroscopy is performed in a systematic fashion. Meniscal tears and other pathology are identified. With use of an arthroscopic probe, the features of the meniscal tear are determined. Arthroscopic punches and shavers are used to debride torn portions back to a stable rim. Knee arthroscopy is a highly effective procedure. Outcomes after partial medial meniscectomy are good to excellent in 80% to 100% of patients. A recent cost-effectiveness analysis demonstrated that knee arthroscopy is more cost-effective than coronary artery bypass surgery or total knee arthroplasty.
PubMed: 30237917
DOI: 10.2106/JBJS.ST.N.00095 -
Medicine Sep 2018Due to the low incidence and lack of effective diagnostic measures for the diagnosis of metal allergy in patients undergoing total joint arthroplasty (TJA), diagnosis... (Review)
Review
RATIONALE
Due to the low incidence and lack of effective diagnostic measures for the diagnosis of metal allergy in patients undergoing total joint arthroplasty (TJA), diagnosis relies mainly on the exclusion of other causes, in particular infection. It remains a relatively unpredictable and poorly understood cause of implant failure. At present, skin patch testing, leukocyte migration inhibition test (LMIT) and lymphocyte transformation tests (LTT) are being commonly used to assess metal hypersensitivity.This report presents both a case and literature review.
PATIENT CONCERNS
A 61-year-old female patient experienced continuous swelling and pain in the right knee joint for 9 months after a right-side total knee arthroplasty (TKA).
DIAGNOSES
We believe this is the case report of metal allergy in TKA. The following were the reasons for this. First, no definite symptoms of infection during revision arthroplasty were observed, but with obvious hyperplasia of synovium. Furthermore, a frozen biopsy revealed an extremely low neutrophil count, which was considered to be caused by chronic inflammation. Second, the results of repeated post-operation reexaminations indicate a clear increase in the number of eosinophils, while no bacteria were found in the tissue bacterial smear performed during the operation. Third, improvements were clearly observed in the patient following synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.
INTERVENTIONS
The patient underwent synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.
OUTCOMES
The patient's right knee remained mildly swollen; however, the pain has been relieved significantly. The range of motion could achieve 0 degrees of extension and 90 degrees of flexion.
LESSONS
No consensus has been reached about the best diagnostic criteria for this disease, and most physicians would consider it to be a possibility when other diseases including periprosthetic joint infection (PJI) have been excluded. Although this case followed the same course, the outcome following synovectomy and anti-anaphylactic treatment further confirmed our hypothesis.
Topics: Arthroplasty, Replacement, Knee; Female; Humans; Hypersensitivity; Knee Prosthesis; Metals; Middle Aged; Polyethylene; Prosthesis Failure; Synovectomy; Synovial Membrane
PubMed: 30235744
DOI: 10.1097/MD.0000000000012475 -
Arthroscopy Techniques Jul 2023Synovial osteochondromatosis is a benign process that most commonly affects the knee joint (70%). It is characterized by proliferative metaplasia of synovial membrane...
Synovial osteochondromatosis is a benign process that most commonly affects the knee joint (70%). It is characterized by proliferative metaplasia of synovial membrane into chondrocytes, resulting in the formation of multiple cartilaginous nodules, which can detach from the synovium to become multiple intra-articular loose bodies. It usually involves the anterior compartment, including infrapatellar fat pad, suprapatellar pouch, and anterior interval, and rarely involves the posterior compartment of the knee. Treatment for synovial osteochondromatosis usually involves surgery, especially in the presence of locking symptoms or decreased range of motion. Arthroscopy has gradually replaced a traditional open approach, resulting in low morbidity, low postoperative pain, better cosmetic results, early recovery of range of motion, short rehabilitation course, and an early return to previous function. In case of involvement of the posterior compartment of the knee joint, arthroscopic access may be difficult. In this Technical Note, the technical details of arthroscopic synovectomy and removal of loose bodies in synovial osteochondromatosis of the knee is described. This arthroscopic technique can deal with the disease, involving both the anterior and posterior compartments of the knee joint.
PubMed: 37533918
DOI: 10.1016/j.eats.2023.02.023 -
Hand (New York, N.Y.) Jan 2021The etiology of recurrent carpal tunnel syndrome (CTS) is unclear, and outcomes following secondary surgery in this demographic have been poorer than primary surgery.... (Review)
Review
The etiology of recurrent carpal tunnel syndrome (CTS) is unclear, and outcomes following secondary surgery in this demographic have been poorer than primary surgery. Fibrosis and hypertrophy have been identified in the flexor tenosynovium in these patients. The authors use flexor tenosynovectomy (FTS) for recurrent CTS after primary carpal tunnel release and present a review of these patients. A retrospective chart review was performed of 108 cases of FTS for recurrent CTS from 1995 to 2015 by 4 attending surgeons at one institution. Demographic information, symptoms, and outcomes were among the data recorded. A phone survey was conducted on available patients where the shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) and satisfaction were assessed. Average office follow-up was 12 months. Average age was 57.5 years. A total of 104 (96%) reported symptom improvement and 48 (44%) reported complete symptom resolution. Forty patients were available for long-term follow-up at an average 6.75 years postoperatively via phone interview. Average QuickDASH score was 31.2 in these patients. Thirty-six (90%) of 40 patients were initially satisfied at last office visit, and 31 (78%) of 40 were satisfied at average 6.9 years, a maintenance of satisfaction of 86%. Satisfied patients were older (58 years) than unsatisfied patients (51 years). Both long-term satisfaction and QuickDASH scores in our cohort are consistent with or better than published results from nerve-shielding procedures. The authors believe a decrease in both carpal tunnel volume and potential adhesions of fibrotic or inflammatory synovium contributes to the benefits of this procedure. This remains our procedure of choice for recurrent CTS.
Topics: Carpal Tunnel Syndrome; Hand; Humans; Middle Aged; Retrospective Studies; Synovectomy; Wrist
PubMed: 30939941
DOI: 10.1177/1558944719840735 -
JBJS Essential Surgical Techniques 2021The goal of the osteochondral autograft transplantation (OAT) procedure is to replace both the bone and cartilage that have been compromised by osteonecrosis of the...
BACKGROUND
The goal of the osteochondral autograft transplantation (OAT) procedure is to replace both the bone and cartilage that have been compromised by osteonecrosis of the capitellum, a condition known as osteochondritis dissecans (OCD). In children, the vascularity of the capitellum is limited compared with that in adults because the physis acts as a physical barrier to vascular ingrowth from the metaphysis to the epiphysis. The necrotic subchondral bone cannot keep up with the weight-bearing demands of certain high-level athletes such as gymnasts, accumulating microfractures and eventually crumbling. Without the support of the subchondral bone, the overlying cartilage fractures and eventually comes loose, often floating around the joint as a loose body. Fibrocartilage may form to fill the void left behind but cannot restore either the structural integrity of the bone or the gliding and compressive properties of hyaline cartilage. Replacement of both the bone and the cartilage requires an osteochondral transplant. Fortunately, there are regions of the articular surface of the knee in which there is minimal load or contact and that are therefore expendable as donor osteochondral plugs. We prefer a single-plug technique whenever possible because it is easier to perform and only requires union of the plug to native bone across 1 interface. If a single plug will not cover the defect or cannot be made to match the contour of the capitellum, multiple plugs may be used (i.e., mosaicplasty).
DESCRIPTION
Place the patient with the operative side up in the lateral decubitus position with the arm in a holder. First, perform a diagnostic elbow arthroscopy. Use the proximal anteromedial portal to insert the scope across the front of the joint. Using a switching stick, make an anterolateral portal. Place a cannula to prevent having to go in and out of the joint multiple times, as this increases the risk of neurologic injury. Perform a synovectomy if necessary and remove any loose bodies. The absence of synovitis is a sign that the lesion has likely healed. Inspect the capitellum and radial head. The anterior margin of the OCD lesion of the capitellum will be barely visible as the joint is brought to extension.If the lesion is readily visible in the anterior compartment, the lesion will be too anterior to approach from an anconeus split approach. In this case, some have advocated a takedown of the lateral collateral ligament to aid in visualization from a lateral approach. We have had good success with a direct anterior approach between the brachialis and brachioradialis, mobilizing the radial nerve laterally.If the chondral injury is extensive or includes the articular surface of the radial head, then the injury is too advanced to successfully treat with an OAT procedure. In these cases, we perform an interposition arthroplasty of the radiocapitellar joint. Radial head resection is not an option in a child because of the high risk of proximal radial migration. Radial head replacement likewise is not an option because of the high risk of failure.Switch the viewing and working portals again with use of switching sticks and repeat the process for the medial side of the joint. Make a direct posterior and a proximal posterolateral portal. Never debride on or near the medial gutter because the ulnar nerve is immediately adjacent. Establish a soft spot portal and place the scope through it. Loose bodies and extensive synovitis are typically seen in this area when the soft spot portal is used as a viewing portal. The OCD lesion should be visible through the soft spot portal. If the lesion is not readily visible with some elbow flexion, then the lesion is probably too anterior for an anconeus split approach and an anterior approach should be considered.Challenge the lesion with a probe. If the cartilage is damaged but the subchondral bone holds firm, perform a microfracture technique. If the cartilage is soft or unstable and the underlying bone is compromised, perform an OAT procedure. In the majority of cases in which the lesion is accessible posteriorly, connect the proximal posterolateral portal and the soft spot portal and split the anconeus. The lesion will be visible in deep flexion. There are several options for instrumentation from multiple manufacturers that each have their own advantages and disadvantages. Using a recipient harvester, remove the diseased bone and cartilage to a stable rim, keeping the harvester as perpendicular to the surface as possible.At the knee, make a 3-cm transverse incision directly over the superolateral corner of the lateral femoral condyle. Harvest an appropriately sized plug from the superolateral corner of the articular surface. Inspect the plug because it will often be slightly thicker on one side. Rotate the plug to match the contour of the defect in the capitellum. Mallet the donor plug into the recipient deficit with gentle taps, using as few taps as possible to limit chondrocyte injury. Fill the defect in the knee with your choice of bone substitute. Close both wounds in layers.
ALTERNATIVES
Other options include allograft plugs, periosteal resurfacing, bone grafting, retrograde and antegrade drilling, and observation.
RATIONALE
The OCD lesion involves both bone and cartilage. There is now ample evidence that replacing both as a unit yields the best outcomes.
EXPECTED OUTCOMES
Approximately 90% of patients will return to sports participation, and 80% of patients can expect to return to sport at their previous level of participation.
IMPORTANT TIPS
A diagnostic arthroscopy confirms the need for the OAT procedure and identifies other pathologies.Remove all of the diseased bone with the recipient harvester.Match the size and contour of the lesion as closely as possible with the plug.Immobilize the elbow in a cast for 4 weeks.
PubMed: 34277134
DOI: 10.2106/JBJS.ST.20.00032 -
Journal of Wrist Surgery Jun 2023Treatment of palmar midcarpal instability (PMCI) remains controversial and children can develop PMCI from asymptomatic hypermobility. Recently, case series have been...
Treatment of palmar midcarpal instability (PMCI) remains controversial and children can develop PMCI from asymptomatic hypermobility. Recently, case series have been published regarding the use of arthroscopic thermal shrinkage of the capsule in adults. Reports of the use of the technique in children and adolescents are rare, and there are no published case series. In a tertiary hand center for children's hand and wrist conditions, 51 patients were treated with arthroscopy for PMCI between 2014 and 2021. Eighteen out of 51 patients carried additional diagnosis of juvenile idiopathic arthritis (JIA) or a congenital arthritis. Data were collected including range of movement, visual analog scale (VAS) at rest and with load, and grip strength. Data were used to determine the safety and efficacy of this treatment in pediatric and adolescent patients. Mean follow-up was 11.9 months. The procedure was well tolerated and no complications were recorded. Range of movement was preserved postoperatively. In all groups VAS scores at rest and with load improved. Those who underwent arthroscopic capsular shrinkage (ACS) had significantly greater improvement in VAS with load, compared with those who underwent arthroscopic synovectomy alone ( = 0.04). Comparing those treated with underlying JIA versus those without, there was no difference in postoperative range of movement, but there was significantly greater improvement for the non-JIA group in terms of both VAS at rest ( = 0.02) and VAS with load ( = 0.02). Those with JIA and hypermobility stabilized postoperatively, and those with JIA with signs of early carpal collapse and no hypermobility achieved improved range of movement, in terms of flexion ( = 0.02), extension ( = 0.03), and radial deviation ( = 0.01). ACS is a well-tolerated, safe, and effective procedure for PMCI in children and adolescents. It improves pain and instability at rest and with load, and offers benefit over open synovectomy alone. This is the first case series describing the usefulness of the procedure in children and adolescents, and demonstrates effective use of the technique in experienced hands in a specialist center. This is a Level IV study.
PubMed: 37223383
DOI: 10.1055/s-0042-1750871 -
OncoTargets and Therapy 2022Tenosynovial giant cell tumor (TGCT) is a neoplasm of the joint synovium that can have severe impacts on joint mobility, function, and quality of life. Traditionally,... (Review)
Review
Tenosynovial giant cell tumor (TGCT) is a neoplasm of the joint synovium that can have severe impacts on joint mobility, function, and quality of life. Traditionally, treatment modalities included partial or complete surgical synovectomy, radiotherapy (typically as an adjunct to surgery), and watchful monitoring (no medical or surgical intervention). However, these approaches have been met with varying degrees of success and high recurrence rates, as well as onerous complications and clinical sequelae. Pexidartinib, a colony-stimulating factor 1 receptor (CSF1R) inhibitor, presents a promising molecular approach that targets a neoplastic driver of TGCT. While the introduction of pexidartinib allows clinicians to avoid the significant morbidity associated with traditional treatment options, there are also defined risks associated with pexidartinib treatment. Therefore, patient selection is critical in optimizing treatment modalities in TGCT. The purpose of this literature review is to identify the TGCT patient population that would derive maximal benefit with minimal risk from pexidartinib, and to determine the specific indications and contraindications for selecting pexidartinib over other therapeutic approaches. Specifically, this paper compares the efficacy and safety profile of pexidartinib across clinical and preclinical studies to that of surgery, radiotherapy, and watchful monitoring. Rates of improvement in joint mobility, pain, and recurrence-free survival across studies of pexidartinib have been encouraging. The most common adverse events are mild (hypopigmentation of the hair) or reversible (transient aminotransferase elevation). Severe or permanent adverse events (notably cholestatic hepatotoxicity) are rare. While the optimal treatment strategy remains highly dependent on a patient's clinical circumstances and treatment goals, pexidartinib has surfaced as a promising therapeutic in cases where the morbidity of surgery or radiotherapy outweighs the benefits.
PubMed: 35046667
DOI: 10.2147/OTT.S345878 -
EFORT Open Reviews May 2019The musculoskeletal problems of haemophilic patients begin in infancy when minor injuries lead to haemarthroses and haematomas.Early continuous haematological primary... (Review)
Review
The musculoskeletal problems of haemophilic patients begin in infancy when minor injuries lead to haemarthroses and haematomas.Early continuous haematological primary prophylaxis by means of the intravenous infusion of the deficient coagulation factor (ideally from cradle to grave) is of paramount importance because the immature skeleton is very sensitive to the complications of haemophilia: severe structural deficiencies may develop quickly.If primary haematological prophylaxis is not feasible due to expense or lack of venous access, joint bleeding will occur. Then, the orthopaedic surgeon must aggressively treat haemarthrosis (joint aspiration under factor coverage) to prevent progression to synovitis (that will require early radiosynovectomy or arthroscopic synovectomy), recurrent joint bleeds, and ultimately end-stage osteoarthritis (haemophilic arthropathy).Between the second and fourth decades, many haemophilic patients develop articular destruction. At this stage the main possible treatments include arthroscopic joint debridement (knee, ankle), articular fusion (ankle) and total joint arthroplasty (knee, hip, ankle, elbow). Cite this article: 2019;4:165-173. DOI: 10.1302/2058-5241.4.180090.
PubMed: 31191984
DOI: 10.1302/2058-5241.4.180090 -
Arthroscopy, Sports Medicine, and... Oct 2022To provide an up-to-date systematic review on the treatment options for pigmented villonodular synovitis (PVNS) of the hip and provide a grade of recommendation using... (Review)
Review
Open or Arthroscopic Synovectomy Is the Preferred Management Option in Pigmented Villonodular Synovitis of the Hip Joint Without Evidence of Degeneration: A Systematic Review of 20 Studies.
PURPOSE
To provide an up-to-date systematic review on the treatment options for pigmented villonodular synovitis (PVNS) of the hip and provide a grade of recommendation using standardized systems.
METHODS
A systematic search of PubMed, Embase, Web of Science, and The Cochrane Library from the date of inception of each database through December 4, 2021, was performed. Studies that described the outcomes of treatment of hip PVNS were identified. These outcomes were discussed and synthesized by three reviewers, and a grade of recommendation was assigned.
RESULTS
Twenty studies were identified. Seven studies described arthroscopic synovectomy, eight studies described open synovectomy, nine studies described arthroplasty, and one study described osmic acid synoviorthesis. Synovectomy, either open or arthroscopic, had similar rates of disease recurrence. Hip arthroplasty had low rates of disease recurrence compared to synovectomy; however, it was associated with significant risk of aseptic loosening in the longer term.
CONCLUSION
Synovectomy, either open or arthroscopic based on surgeon preference, is favored in the treatment of hip PVNS if there is no evidence of joint space narrowing. Arthroplasty should be considered in cases with joint space narrowing or recurrence following joint preservation therapy. There is insufficient evidence to support synoviorthesis either as monotherapy or adjuvant therapy.
LEVEL OF EVIDENCE
IV, systematic review of Level III and IV studies.
PubMed: 36312712
DOI: 10.1016/j.asmr.2022.06.008 -
SICOT-J 2020Chronic synovitis involving a single large joint remains a diagnostic dilemma. We present 61 cases of chronic synovitis of the knee, followed prospectively for 2 years....
INTRODUCTION
Chronic synovitis involving a single large joint remains a diagnostic dilemma. We present 61 cases of chronic synovitis of the knee, followed prospectively for 2 years. The study focuses on the diagnosis, management, and histopathological correlation.
METHODS
We prospectively studied 61 patients with chronic mono-articular synovitis of the knee joint, between July 2016 and September 2017. All patients underwent plain radiographs, magnetic resonance imaging, and arthroscopic examination with synovial biopsy. Further treatment was based on findings of histopathological examination.
RESULTS
The average duration of symptoms was 7.72 ± 4.34 months. The mean age at presentation was 29.93 ± 15.56 years. Results of histopathological examination showed chronic nonspecific inflammation in 28 patients (46%), features suggesting tubercular infection in 19 patients (31%), pigmented villonodular synovitis in seven patients (11.5%), rheumatoid arthritis in three (5%) patients, acute inflammation in three (5%) patients and findings suggestive of synovial chondromatosis in one (1.5%) patient. Treatment was based on histopathological results. Intra-articular injections of methylprednisolone (80 mg depot preparation) were given to all patients with nonspecific synovitis and rheumatoid arthritis. Anti-tubercular treatment was started for patients with tubercular synovitis. Complete arthroscopic/open synovectomy followed by radiotherapy was carried out for patients with pigmented villonodular synovitis. Non-steroidal anti-inflammatory drugs are used for patients with acute on chronic inflammation. All patients had symptomatic relief and functional improvement in further follow-up.
DISCUSSION
Histopathological reporting remains the mainstay for diagnosis. The various differentials should always be kept in mind when approaching patients with chronic mono-articular synovitis. Specific treatment can be started once the diagnosis is confirmed.
PubMed: 33306021
DOI: 10.1051/sicotj/2020044