关节镜下诊治膝关节弥漫性色素沉着绒毛结节性滑膜炎

目的 探讨采用关节镜技术诊治膝关节弥漫性色素沉着绒毛结节性滑膜炎的临床疗效.方法 自2009年3月至2011年5月关节镜下诊治膝关节弥漫性色素沉着绒毛结节性滑膜炎7例,先行后内、后外侧间室的清理,然后清理髁间窝,交叉韧带表面,前内、外侧间室,内、外侧沟,最后行髌上囊清理,病变组织均送病检.术后常规放置引流管,按计划指导功能训练.结果 本组7例患者有4例MRI发现结节病变,诊断为弥漫性绒毛结节性滑膜炎;3例镜检发现术前穿刺液为鲜血或淡黄色液或褐色液.1例伴外侧半月板复杂撕裂;2例合并不同程度的骨关节炎.无一例发生膝关节感染.术后2例行放疗.全部患者获得随访,随访时间12.0~32.0个月,平均21.4月,无膝关节活动受限,未见复发病例.所有患者对术后疗效表示满意.Lysholm膝关节的功能评分由术前的50.7分增加到86.6分.结论 关节镜技术诊治膝关节弥漫性色素沉着绒毛结节性滑膜炎是一种创伤小,恢复快,病灶切除彻底,能有效地避免复发的治疗方法.     

Diagnosis and surgical therapy of diffuse pigmented villonodular synovitis of the hip joint

Pigmented villonodular synovitis (PVNS) of the hip is a monoarticular proliferative process involving the synovial membrane. A chronic inflammation as well as a neoplastic process have been proposed in the literature. PVNS is usually found in adults aged 20-50 years, without sex predilection. The knee is by far the commonest location, followed by the hip. We present a detailed case report of a 25-year-old man with PVNS of the hip. The physical examination was completely normal. Radiographs of the hip show erosions in the head and neck of the femur and the acetabulum. Magnetic resonance imaging showed a suspected malignant soft tissue mass involving the hip joint. The diagnosis of PVNS was confirmed by arthroscopy and biopsy, and the treatment of choice was an open synovectomy. One year after the operation the clinical examination was normal.     

A case of aggressive pigmented villonodular synovitis

An unusual case of pigmented villonodular synovitis affecting a knee joint is described. Shortly after synovectomy, extensive bone and ligament destructions occurred and made conservative surgery impossible.     

A case of aggressive pigmented villonodular synovitis

An unusual case of pigmented villonodular synovitis affecting a knee joint is described. Shortly after synovectomy, extensive bone and ligament destructions occurred and made conservative surgery impossible.     

四肢关节色素性绒毛结节性滑膜炎的骨侵袭性

目的：探讨色素性绒毛结节性滑膜炎对周围骨质侵袭的机理、临床诊断和外科治疗。方法：７例四肢骨关节内的色素性绒毛结节性滑膜炎经手术病理确诊。发生在膝关节３例、髋关节３例、踝关节１例。Ｘ线片见发生在膝关节为侵入性骨质破坏,发生在髋、踝关节多为关节面的腐蚀性破坏。结果：７例均行关节内病变的滑膜组织切除术,并对受累的骨质进行刮除。随访１月～１０年,无局部复发。结论：色素性绒毛结节性滑膜炎侵及骨质较少见,临床表现及Ｘ组片更无典型特征,术前确诊率不高。治疗以滑膜彻底切除为主,对与骨质粘连明显的病例,可行关节盛开有术或关节置换术。     

Joint replacement in the hallux metatarsophalangeal joint

Joint replacement of the hallux metatarsophalangeal joint has not enjoyed the same success as hip and knee arthroplasties. Silastic implants have achieved a high patient satisfactory rate but have caused many complications, including silicone synovitis and lymph node inflammation. Metal and polyethylene hemiarthroplasties and total toe replacements seem to be more promising although results are preliminary. Problems with these implants seem to be related to soft tissue instability of the joint; patients who have hallux rigidus have more success than patients who have hallux valgus or rheumatoid arthritis. Severe complications can be treated with removal and synovectomy or arthrodesis, depending on the length and alignment of the foot, as well as the functional demands of the patients. It would be beneficial to have more data on these implants so that improvements can be made in design and patient selection.     

Extraarticular pigmented villonodular synovitis: a cause for failed knee arthroscopy

Arthroscopic treatment of diffuse pigmented villonodular synovitis of the knee is reported to have low recurrence rates and morbidity. The purpose of the current study was to evaluate demographic information, clinical symptoms, treatment parameters, and functional outcome in a group of 38 consecutive patients referred to the authors' hospital with persistent extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. There were 23 males and 15 females with an average age of 31.7 years (range, 11-65 years) at the time of arthroscopy. All had an average of 1.7 (range, 1-5) arthroscopies. Thirty-four of 38 (89.5%) patients had some improvements of their symptoms after arthroscopic synovectomy, but all had worse symptoms and function at the latest followup of 3.63 years (range, 0.25-19.5 years). Although arthroscopic synovectomy offered some short-term relief, a critical review of prior reports and the data in the current study suggest poor outcomes in patients who have extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. Magnetic resonance imaging is recommended for accurate staging of the disease and for long-term followup after arthroscopic treatment.     

Aseptic synovitis after meniscal repair using the biodegradable Meniscus Arrow

We report a case of aseptic synovitis in a 19-year-old man. The synovitis of the left knee developed 13 months after meniscal repair using the biodegradable Meniscus Arrow (Bionx Inc, Malvern, PA). Histologic examination revealed chronic nonspecific synovitis and birefringent materials. Immunohistochemical tests were positive in lysozyme, α-1-antitrypsin, and α-1-antichymotrypsin. After arthroscopic synovectomy, pain and swelling of the knee joint were relieved and the patient's range of motion fully recovered. We have found no previous report of aseptic synovitis accompanying meniscal repair using the biodegradable Meniscus Arrow.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 77–80     

Severe metallosis-related osteolysis as a cause of failure after total knee replacement

BackgroundMetallosis is a syndrome of metal-induced synovitis caused by friction between two metal surfaces. In contrast to the hip joint after resurfacing arthroplasty or metal-on-metal (MoM) total hip replacement, metallosis of the knee is extremely rare.MaterialsWe describe 4 patients who underwent revision total knee replacement because of disabling pain and implant loosening after a mean time of 21 (range: 13–30) years of knee replacement surgery. They were all females with a mean age of 79 (range: 75–82) years. Septic loosening was excluded through microbiological examination and synovial fluid analysis.ResultsDirect metal-on-metal contact at the tibiofemoral interface was confirmed intraoperatively in all cases. All knees showed severe metallosis with advanced osteolysis and pseudotumor formation. In one knee there was a complete fracture of the tibial tray. All patients had a one-stage revision surgery with implant removal, profound synovectomy and implantation of a constrained modular revision knee system. Long modular stems with offset adapters, wedges and/or blocks were used in all cases.ConclusionMetallosis-associated osteolysis should be suspected in cases with radiologically evident polyethylene wear after knee replacement. Recognizing that revision arthroplasty is very technically demanding in such cases, surgeons should have a back-up with modular revision components and a ready access to reconstructive options at this revision setting.     

Diagnosis and classification of mandibular osteomyelitis.

To establish a unified classification system for mandibular osteomyelitis, various diagnostic terms were critically assessed and clinicopathologic findings of the lesions were carefully reviewed. We recommend classifying mandibular osteomyelitis into bacterial osteomyelitis and osteomyelitis associated with the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. Other diagnostic terms were excluded because they were not appropriate for classification. Diagnostic criteria for bacterial osteomyelitis are suppuration and osteolytic change. The lesions are easily cured by antibiotic treatments. Mandibular osteomyelitis in SAPHO syndrome is characterized by nonsuppuration and a mixed pattern on radiography, with solid type periosteal reaction, external bone resorption, and bone enlargement. The presence of osteomyelitis in other bones, arthritis, or skin diseases (palmoplantar pustulosis, pustular psoriasis, and acne) strongly suggests this syndrome. Antibiotic therapy is usually ineffective and the symptoms of SAPHO syndrome are often persistent.     

Arthroscopic treatment of chronic synovitis of the ankle

Arthroscopic synovectomy is a valuable tool in treating synovitis of the knee joint. We have identified a group of patients who benefit from ankle synovectomy. To determine the indications and long-term results of arthroscopic synovectomy of the ankle, we evaluated the history, preoperative examination, roentgenograms, and operative data of patients who underwent this procedure and had a minimum of 2 years of follow-up. Sixteen patients who underwent arthroscopic ankle synovectomy were identified. Sprains and inversion-type injuries were common in this young patient group. All had failed conservative therapy. Operative findings revealed hypertrophic synovium in all cases. Good or excellent results were obtained in 75% of patients, using a subjective and functional evaluation scale. Complications were one deep infection, one superficial infection, and one temporary sensory paresthesia. Chronic synovitis, or anterior soft-tissue impingement, was responsive to arthroscopic treatment and results did not deteriorate over time.     

A case of pigmented villonodular synovitis of the elbow joint with bone invasion

Pigmented villonodular synovitis is a benign proliferative disorder of the joint and of the tendon sheath synovium. It has a predilection for the lower extremities, particularly the knee and the hip. The elbow joint is rarely affected. A 56-year-old woman had complaints of pain and swelling in the left elbow for three years. She had no history of trauma. On physical examination, she had swelling of the left elbow, varus deformity, and flexion contracture of 20 degrees. Active and passive joint movements were painful. Magnetic resonance imaging showed synovial thickening and signal changes. An incisional biopsy yielded a diagnosis of pigmented villonodular synovitis. She underwent subtotal synovectomy and excision of the radius head. No evidence of clinical or radiologic recurrence was detected within a follow-up of 16 months.     

The shoulder joint in chronic polyarthritis

In patients with rheumatoid arthritis, shoulder problems are very common. In the present study, 96 of 105 patients, i.e., 91%, reported shoulder problems. Thirty-one percent of the patients had such severe shoulder disability that they considered it to be their main rheumatic problem. With increasing duration of the rheumatic shoulder disease, there are progressive destructive changes and a decrease in the range of motion and functional capacity even with conservative treatment, indicating that intervention with surgical procedures may be warranted. In the early effusive stages of rheumatic shoulder disease, radiological synovectomy with beta-emitting radionuclides may be indicated. In proliferative synovitis, surgical synovectomy gives good pain relief and increased shoulder mobility and function. In shoulders with more advanced painful shoulder arthropathy, shoulder replacement is gaining in popularity. However, it is mandatory that candidates must be selected very carefully for shoulder replacement and in patients with severe fibrotic capsulitis, muscular atrophy or mutilation with severe loss of bone, the results after shoulder replacement surgery are often less successful.     

Role of pulsed electromagnetic fields after joint replacements

Although the rate of patients reporting satisfaction is generally high after joint replacement surgery, up to 23% after total hip replacement and 34% after total knee arthroplasty of treated subjects report discomfort or pain 1 year after surgery. Moreover, chronic or subacute inflammation is reported in some cases even a long time after surgery. Another open and debated issue in prosthetic surgery is implant survivorship, especially when related to good prosthesis bone ingrowth. Pulsed Electro Magnetic Fields(PEMFs) treatment, although initially recommended after total joint replacement to promote bone ingrowth and to reduce inflammation and pain, is not currently part of usual clinical practice. The purpose of this review was to analyze existing literature on PEMFs effects in joint replacement surgery and to report results of clinical studies and current indications. We selected all currently available prospective studies or RCT on the use of PEMFs in total joint replacement with the purpose of investigating effects of PEMFs on recovery, pain relief and patients' satisfaction following hip, knee or shoulder arthroplasty. All the studies analyzed reported no adverse effects, and good patient compliance to the treatment. The available literature shows that early control of joint inflammation process in the first days after surgery through the use of PEMFs should be considered an effective completion of the surgical procedure to improve the patient's functional recovery.     

Pigmented Villonodular Synovitis of the Hip Presenting as a Buttock Mass Treated by Total Hip Arthroplasty

Pigmented villonodular synovitis (PVNS) of the hip is a relatively uncommon benign but locally aggressive disease that should be considered in younger patients presenting with monoarticular joint symptoms. Pigmented villonodular synovitis begins in and usually remains confined within a synovium-lined joint, but rarely, it may extend beyond the joint capsule and present as a soft tissue mass. The authors report a previously unrecognized presentation of PVNS of the hip in a 36-year-old man, who presented with a buttock mass arising from the right hip joint. The patient was treated by synovectomy and total hip arthroplasty.     

Synovectomy of the knee for hemophilic arthropathy

Synovectomy of the knee for the control of recurrent hemarthrosis was performed in thirteen patients with hemophilic arthropathy. Preoperatively, all patients had experienced an average of three bleeding episodes into the affected joint per month, and had been unresponsive to at least six months of medical management. Radiographically, all knees had either Stage-II or Stage-III hemophilic arthropathy. The average age of the patients at the time of synovectomy was sixteen years and the average length of follow-up was 7.3 years (range, two to eleven years and seven months). Although the motion of the knee remained unchanged postoperatively in two patients, ten patients had an average loss of 41 degrees. One patient eventually required an arthrodesis. Radiographically, there was slight further joint deterioration after synovectomy, and no knee progressed beyond Stage-III hemophilic arthropathy. Only one patient in our series had a recurrent spontaneous hemarthrosis of the synovectomized knee, although two others had traumatic bleeding episodes. The complications included three immediate postoperative hemarthrosis requiring surgical evacuation, isoimmune hemolytic anemia in one patient, patellofemoral adhesions in two knees, and a total fibrous ankylosis that required a knee arthrodesis in one patient. It was concluded from our study that chronic recurrent hemarthrosis and the pain associated with persistent synovitis in the hemophilic knee can be effectively eliminated for as many as twelve years after open synovectomy, although usually with significant loss of motion of the knee. This procedure also appeared to slow the progression of arthropathy, and no patient had been considered for a total knee replacement at the time of writing.     

Use of polymethylmethacrylate to treat pigmented villonodular synovitis in the posterior compartment of the knee

Pigmented villonodular synovitis (PVNS) is a benign process that mainly affects the knee joint. There are two types of PVNS, a localised and a diffuse form. Although adjuvant therapies are possible, the treatment consists of arthroscopic or open synovectomy of the affected area. The most common complication is local recurrence. We report the case of a patient with PVNS and osteolysis of the femoral condyle, treated with anterior arthroscopic synovectomy and posterior approach for the treatment of the femoral condyle erosion. The bone erosion was treated with polymethylmethacrylate (PMMA) cement. There are no publications indexed in our knowledge that explain the treatment of PVNS associated with bone erosion by PMMA. Nine years after the procedure, the patient is leading a fully active life with no evidence of active disease.     

髋关节色素沉着绒毛结节性滑膜炎的诊断与治疗

目的 探讨髋关节色素沉着绒毛结节性滑膜炎的发病特点及治疗方法。方法 23例髋关节色素沉着绒毛结节性滑膜炎，采用髋关节前外侧改良S-P切口入路，将股骨头脱位后，直视下彻底清除病变滑膜组织，并予股骨头植入血管束。结果 随访6个月-11年，平均随访3.78年，所有病例术后髋关节疼痛缓解，功能改善，无复发，亦未发生股骨头坏死，11例随访4年以上者髋臼缘有骨赘增生，其中7例时有关节轻度疼痛，无1例因关节疼痛或髋关节功能不良而要求行髋关节置换。结论 髋关节色素沉着绒毛结节性滑膜炎有独特的临床及影像学表现；采用彻底清除滑膜及血管束植入的方法。既可防止复发又可预防股骨头坏死，是治疗该病的有效方法。     

Rheumatological management of patients with hemophilia. Part 1: joint manifestations

The advent of factor VIII and IX replacement therapy has radically changed the physiognomy of hemophilia. In patients with no inhibitors, early replacement therapy shortens the immobilization and decreases the structural and functional alterations related to recurrent hemarthrosis. Routine prophylactic replacement therapy before or after the first episode of hemarthrosis is still rarely used in France. Recurrent hemarthrosis in the same joint can cause synovitis and chronic arthropathy. Injection synovectomy is now the preferred treatment, as opposed to secondary prophylactic replacement therapy and to arthroscopic or open synovectomy. The palliative treatment of chronic arthropathy is difficult and rests on analgesics and rehabilitation therapy, with orthotic devices and/or surgery where appropriate. The treatment of hemophilia is far more difficult in patients with inhibitors and, consequently, considerable hope is being placed in gene therapy, whose first results are encouraging.     

Use of arthroscopic arthroplasty in the treatment of patients with degenerative diseases of the knee joint]

An analysis of results of treatment of 38 patients with 40 degenerative injuries of the knee joint by arthroscopic arthroplasty shows clinical effectiveness of this method only in cases with light and medium degrees of gravity of the disease. The absence of clinical effects of the complex conservative treatment of patients with osteochondrosis and persistent painful syndrome, mechanical symptoms of disturbances in the joint, recurring synovitis can be considered as indications for arthroscopic operations. The probability of achievement of positive results of arthroscopic treatment is higher in patients with the I-III degrees of injuries of the cartilage and IV degree--with a full thickness defect of the articulation surface as big as 1 cm in diameter in one part of the knee joint and on one of the joining condyles.