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.

Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients.

INTRODUCTION: Only few case series of capitellar and trochlear fractures have been reported. Some of them assume that the presence of a posterior comminution (type B according to Dubberley classification) can represent a negative risk factor for treatment and prognosis respect to the type A cases (without posterior comminution). Nevertheless, how this parameter impacts the treatment and the prognosis has never been quantified before. MATERIALS AND METHODS: All the capitellar and trochlear fractures treated from 2007 to 2015 have been retrospectively reviewed. The presence of posterior comminution on a pre-operative CT-scan was correlated to the surgical technique, to the timing of initiation of rehabilitation and to clinical outcomes. RESULTS: 45 Consecutive patients have been selected, 17 not presenting a posterior comminution (type A), and 28 with posterior comminution (type B). In all the type A fractures a lateral approach (Kocher o Kocher extensile) was used and the fragment fixation was always performed using only screws. Elbow replacement or olecranon osteotomy were performed only to treat type B fractures. Augmented fixations, using plates and k-wires, or prosthetic replacement have been used only in type B fractures. The post-operative immobilization was significantly inferior for type A fracture. Better results have been obtained in type A fractures: mean MEPI score was 86 in type A and 73 in type B, the range of motion was significatively higher in type A both in flexion-extension and in pronation-supination. In type B fractures a significant higher number of complications have been observed (64% vs 29%) along with more reoperations. DISCUSSION: The study has confirmed that, even without considering the extension of the fracture on the coronal plane, the presence of posterior comminution represents an evident negative risk factor, influencing the surgical approach and treatment, the fixation technique, the post-operative rehabilitation, the clinical outcomes, the complications and re-operation rates. CONCLUSIONS: The analysis of the present case series shows how the treatment and the outcomes can be significantly anticipated based on the presence or absence of posterior comminution. Patients with type A fracture are more likely treated with a Kocher approach, screw fixation, an early rehabilitation is performed. In type A fractures better outcomes and low complications rate are expected.

Traumatic patellar dislocation: loose bodies and the MPFL.

Traumatic patellar dislocation is a common occurrence in adolescents. Treatment in the acute situation is controversial but should always address replacement or removal of osteochondral loose bodies. Reconstruction of the medial patellofemoral ligament in the acute and recurrent situation has provided excellent results in this select patient group.

Intra-articular loose body removal during hip arthroscopy.

Loose bodies are common findings in hip arthroscopy. Loose body removal can be challenging because of the inner position of the acetabulum in which the loose bodies tend to accumulate. Moreover, the standard removal procedure of a considerable number of loose bodies may need a long time under limb traction, thereby increasing the risk of complications. This article describes a new easy method for intra-articular loose body removal. A flexible endotracheal catheter, connected with suction system, is inserted via the anterior or midanterior portal. The catheter can easily be directed toward the inner parts of the joint in proximity of loose bodies. The suction system allows the loose body to be captured in contact with the tip of the catheter, which is then retrieved carrying the loose body outside the cannula. We performed this technique on 4 consecutive patients with synovial chondromatosis. Patients were evaluated preoperatively and 1 month postoperatively by completing self-administered questionnaires. The technique effectiveness was evaluated in terms of overall surgery time, traction time, radiographic appearance of loose bodies left in situ, and postoperative complications. Mean overall surgery time and central time was 175 and 78 minutes, respectively. All patients showed improvement in the operated hip. All radiographs showed hip joint space free of osteochondral loose bodies. No patients reported paraesthesia, nerve palsy, or other postoperative complications. This technique allows for retrieval of a greater amount of loose bodies in a short time, reducing the possibility of undesirable complications.

Factors affecting recovery after arthroscopic labral debridement of the hip.

PURPOSE: The purpose of this study was to develop and validate a model predicting whether patients would have shorter-than-typical or longer-than-typical recoveries after hip arthroscopy for labral tears. METHODS: We retrospectively reviewed 268 cases of hip arthroscopy implemented between 2000 and 2007 by 2 orthopaedic surgeons at our institution. The development cohort consisted of patients with magnetic resonance angiography-identified labral tears and a history and physical examination consistent with either labral pathology or loose bodies. Univariate analysis targeted preoperative patient characteristics correlated with the risk of longer-than-typical recoveries. Multivariate logistic regression was applied to generate an algorithm predicting risk of longer-than-typical recovery based on baseline characteristics. The algorithm was tested in the validation sample of 52 patients who were treated in 2007 and was found to be valid. RESULTS: Five predictors for longer-than-typical recovery were identified: Workers' Compensation status, female gender, use of pain medications, presence of a limp, and presence of a lateral labral tear. The multivariate algorithm was developed and successfully validated. CONCLUSIONS: This study identifies many new predictors of recovery, and it also corroborates those that have already been identified. The 5 predictors for longer-than-typical recovery identified by our validated multivariate algorithm were Workers' Compensation status, female gender, use of pain medications, presence of a limp, and presence of a lateral labral tear. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

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.

Tratamiento quirúrgico de la osteoartritis en la cadera: actualidades en artroscopia de cadera / Surgical treatment of hip osteoarthritis: hpdete on hip arthroscopy

La cirugía artroscópica de cadera es un procedimiento habitual en cada vez más instituciones en el mundo. Las indicaciones de este procedimiento aumentan a medida que se adquiere más experiencia. Gracias a la artroscopia de cadera se ha identificado lesiones, como roturas de labrum y lesiones condrales y de ligamento redondo, que pueden contribuir a la génesis de la osteoartritis en la cadera. También se han transformado técnicas de cirugía abierta de cadera a técnicas artroscópicas, como en el caso del pinzamiento femoroacetabular. Se sabe que el pinzamiento femoroacetabular puede contribuir al desarrollo de osteoartritis en la cadera. La cirugía artroscópica de cadera tiene escasa utilidad en el tratamiento de la osteoartritis formalmente establecida y sólo se debe utilizarla en casos con cambios degenerativos mínimos en pacientes jóvenes (AU)

Arthroscopic surgery of the hip is a routine procedure in an increasing number of institutions around the world. Indications for this procedure increase as more experience is developed. Thanks to hip arthroscopy some intraarticular lesions like labral or ligamentum teres tears and cartilage lesions have been recognized. All of these have the potential to develop hip osteoarthritis. Open techniques for the treatment of femoroacetabular impingement have been transformed to arthroscopic techniques. Femoroacetabular impingement has the potential to cause hip osteoarthritis. The role of hip arthroscopy in the treatment of formally established hip osteoarthritis is limited and has better results in young patients with early degenerative changes (AU)

Ulnar collateral ligament of the elbow.

Recent advances in the diagnosis and treatment of the overhead athlete's elbow has led the medical community to understand that the ulnar collateral ligament (UCL) of the elbow is more commonly injured than originally thought. Injury can result in secondary symptoms and problems in other regions of the elbow. Sports requiring an overhead motion, such as throwing a ball, hitting a ball overhead, or serving a tennis ball, imparts a valgus stress on the elbow that is resisted by the UCL. Throwing sidearm or hitting a forehand in tennis, squash, or racquetball may also impart a valgus stress to the elbow. Repeated or excessive valgus stress places a force on the UCL that may result in injury to the ligament. Injury to the UCL may result in problems in other areas of the elbow, including the ulnar nerve, the flexor-pronator musculotendinous unit, the radiocapitellar joint and the posterior compartment of the elbow, in addition to being a cause of loose bodies within the elbow. This article reviews the anatomy, biomechanics, and pathophysiology of injury to the UCL and injuries to the other structures that result from UCL injury. Also reviewed are patient history, examination techniques, tests that help confirm the diagnosis of UCL injury, and treatment of the injured UCL.

Elbow injuries in throwing athletes: a current concepts review.

Repetitive overhead throwing imparts high valgus and extension loads to the athlete's elbow, often leading to either acute or chronic injury or progressive structural change. Tensile force is applied to the medial stabilizing structures with compression on the lateral compartment and shear stress posteriorly. Common injuries encountered in the throwing elbow include ulnar collateral ligament tears, ulnar neuritis, flexor-pronator muscle strain or tendinitis, medial epicondyle apophysitis or avulsion, valgus extension overload syndrome with olecranon osteophytes, olecranon stress fractures, osteochondritis dissecans of the capitellum, and loose bodies. Knowledge of the anatomy and function of the elbow complex, along with an understanding of throwing biomechanics, is imperative to properly diagnose and treat the throwing athlete. Recent advantages in arthroscopic surgical techniques and ligament reconstruction in the elbow have improved the prognosis for return to competition for the highly motivated athlete. However, continued overhead throwing often results in subsequent injury and symptom recurrence in the competitive athlete.

A locked knee in extension: a complication of a degenerate knee with patella alta.

We present a case of superior dislocation of the patella trapped by interlocked osteophytes. Unlike previous reports, in which the mechanism resulted from a blow to the inferior pole, it is postulated that increased load on the extensor mechanism, combined with patella alta and patellofemoral osteophytes, caused locking of the knee in extension.

Debridement arthroplasty for osteoarthrosis of the elbow: 50 patients followed mean 5 years.

The characteristics and surgical outcome of debridement arthroplasty were investigated in athletes and manual laborers with osteoarthrosis of the elbow. There were 26 elbows in athletes, and 24 elbows in laborers. The mean age was 32 years in athletes and 50 years in laborers. The osteoarthrosis was mainly mild in athletes, but moderate or severe in laborers. Debridement arthroplasty, consisting of resection, osteophytes and removal of loose bodies, was performed in all cases. The medial approach was most frequently employed. Surgery relieved pain and improved range of motion at an average follow-up of 59.5 months. Evaluation of the long-term outcomes at more than 5 years showed recurrence of mild osteoarthrosis with minimal symptoms. Debridement arthroplasty is an effective treatment in athletes and manual laborers with osteoarthrosis of the elbow.

The arthroscopic management of osteochondritis dissecans of the adolescent elbow.

The management of avascular necrosis of the capitellum of the adolescent elbow continues to be a dilemma. This article is a critical retrospective analysis of 12 pediatric patients (mean age at surgery 14.5 years) who underwent arthroscopic debridement alone followed by early range of motion. Follow-up at a mean of 3.2 years (range, 2.0 to 5.7 years) indicated that the average flexion contracture improved from 23 degrees preoperatively to 10 degrees postoperatively. All patients had remodeling of the capitellum by plain radiographs; however, five patients had associated enlargement of the radial head. Eleven patients had minimal mechanical symptoms after the procedure and were highly satisfied. One patient had substantial enlargement of the radial head with continued loss of supination and mechanical symptoms requiring radial head resection 2 years after the index procedure. Five patients had a triangular avulsion fragment present off the lateral capsule. A statistically significant worse subjective outcome was associated with the presence of this fragment (P < .005). There were no complications.

Loose joint bodies of the temporomandibular joint: a case report.

Osteochondral loose bodies are an uncommon finding in the temporomandibular joint (TMJ), but occur relatively frequently in large joints such as the knee, elbow, hip, wrist, and ankle. Loose joint bodies can be divided in three groups: 1) synovial chondromatosis; 2) osteochondral fracture fragments and; 3) cases of degenerative arthritis or avascular necrosis. The most common clinical features of loose joint bodies are pain, swelling, joint noise and impaired joint movements. A case of loose joint bodies of the temporomandibular joint is presented. The pantomograph and lateral cephalograph revealed several irregularly shaped, variably sized radiopaque structures in the region of the right temporomandibular joint. CT and MR scans confirmed the initial diagnosis. The dimensions of the loose joint bodies varied from 1-2 to 5-6 mm. In this patient, the loose joint bodies may have been secondary to osteoarthritis, may have preceded and caused the degenerative changes, or may be only a coincidental finding.

Multiple loose bodies: formation, revascularization, and resorption. A 29-year followup study.

A 45-year-old patient sustained a traumatic dislocation of 1 hip. During a 29-year period, 10 to 13 multiple calcified loose bodies developed slowly in the hip. These first grew in size and became very radiodense, but later showed progressively less radiodensity. Progressive osteoarthritis of the hip was the indication for hip arthrotomy. The loose bodies had become reattached to the synovial surface of the hip joint and were revascularized, having converted from calcified cartilage to bone. This case dramatically shows the body's mechanism for attempting to remove loose bodies from joints.

[Arthroscopy of the elbow joint. Long-term results, complications and indications]. / Arthroskopie des Ellenbogengelenks. Langzeitergebnisse, Komplikationen und Indikationen.

UNLABELLED: Based on the results of a retrospective study of 67 patients who had diagnostic and surgical arthroscopy of the elbow from 1977 until 1990, we present the technique, results, complications, and indications for elbow arthroscopy. The average age of the patients was 26 years (range: 11-59). At follow-up, the patients were examined both clinically and radiologically. The results were scored according to Figgie's score, which contains the criteria of pain, function, power, and range of motion. The overall score increased significantly from 61.6 preoperatively to 85.3 postoperatively. The age of the patient did not influence the results. However, patients who were laborers had a poorer outcome than the others. Patients with a preoperative pain of 4 months to 2 years had better results than patients with a preoperative course of more than 2 years. With respect to the criteria (pain, function, power, range of motion), the pain improved significantly, whereas the other parameters showed no significant improvement. Breaking the diagnosis down into three categories (specific diagnosis, degeneration, unclear diagnosis), only patients with a specific and clear preoperative diagnosis showed significant improvement. The high number of neurological complications was especially striking. CLINICAL RELEVANCE: According to our results, patients with loose bodies, early rheumatoid arthritis, and joint infection seem to be good candidates for elbow arthroscopy. However, patients with severe degeneration or patients with unclear preoperative diagnosis will rarely benefit from this procedure. In general, the patients' pain can be treated effectively, but range of motion or power will not increase after elbow arthroscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

Total hip arthroplasty in high congenital dislocation. 21 hips with a minimum five-year follow-up.

Total arthroplasty was performed on 21 congenitally dislocated hips in 18 women. In all cases the femoral head was dislocated cranially at least one-fifth of the height of the pelvis. The components were both cemented, the acetabulum being replaced to its original position. The acetabular roof was reconstructed by bone graft in 13 hips, and trochanteric osteotomy was done in 18 hips. The patients were assessed at a median follow-up time of 7.5 years when their median age was 54 years. Nine patients had been revised or required revision. At follow-up the average functional score (according to Charnley) was 6 for pain, 4 for walking ability and 5 for range of motion. The Harris hip score was 82. The patients' subjective evaluation of their satisfaction with the late results on a visual analogue scale was 93, range 23 to 100. The high loosening rate in such patients demands regular follow-up and preparedness for revision surgery.

Synovial chondromatosis.

Two patients were evaluated for a complaint of long-standing hip pain. No etiology of their progressively disabling symptoms was found by routine diagnostic studies. Hip arthrography and arthrotomography in each case, however, demonstrated multiple intraarticular filling defects consistent with nonradiopaque loose bodies. These were subsequently confirmed at arthrotomy. Synovial chondromatosis is a rare disease in which intrasynovial cartilage metaplasia results in multiple intracapsular loose bodies. Its presence in plain radiographs is uncommon, but has been previously documented. This can account for frequent long delays in accurate diagnosis. Arthrography and/or arthrotomography, however, can be key diagnostic tools. They are recommended in the evaluation of patients whose relatively normal initial clinical examination, laboratory, and roentgenographic studies fail to adequately explain the presence of genuinely disabling symptoms.