Elbow arthroscopy for loose bodies.

Arthroscopy is highly useful for the diagnosis and treatment of loose bodies of the elbow. Not all loose bodies are detected radiographically, and often there are multiple loose bodies, sometimes both anteriorly and posteriorly. When not complicated by an underlying disorder such as arthritis, loose bodies can be removed from any part of the elbow to provide excellent results in a predictable manner. This article describes techniques developed for the safe and effective application of this procedure in the elbow.     

关节镜下小切口治疗髋关节滑膜软骨瘤病

2004年7月～2009年10月,我们采用关节镜结合小切口治疗3例髋关节滑膜软骨瘤病患者,取得较好效果,报道如下.     

Hip arthroscopy to remove loose bodies after traumatic dislocation

OBJECTIVES: This study was designed to review the incidence of arthroscopically detected intra-articular loose bodies found in patients after traumatic hip dislocation or small acetabular wall fracture which would not otherwise be treated without surgery. DESIGN: Retrospective review. SETTING: Level 1 academic trauma center. PATIENTS: Thirty-six patients who sustained traumatic hip injuries and subsequently had 39 hip arthroscopies between November 1997 and January 2004 were reviewed. INTERVENTION: All patients had standard AP pelvis x-rays and CT scans performed. At our institution, patients with hip dislocations or acetabular wall fractures not otherwise requiring surgery are routinely offered hip arthroscopy to remove loose bodies. The radiographs were reviewed to determine incidence of loose bodies or nonconcentric reduction before hip arthroscopy. Chart review provided incidence of loose bodies found during arthroscopy. MAIN OUTCOME MEASUREMENTS: Comparison was made between radiographic data obtained preoperatively and operative findings. RESULTS: Loose bodies were found in the hips of 33 of 36 patients (92%) who were arthroscoped. Loose bodies were found in 7 of 9 cases (78%) in which standard radiographic studies (AP pelvis x-rays and CT scan) found no loose bodies and a concentric reduction. CONCLUSIONS: Loose bodies are routinely present after closed treatment of hip dislocations or wall fractures not otherwise requiring surgery, even when radiographs are negative. Hip arthroscopy may be indicated for loose body removal when open treatment is not otherwise necessary.     

The role of hip arthroscopy in the elite athlete

Intraarticular hip disorders in the elite athlete are a relatively rare but serious potential consequence of high-level competition. Axial and torsional forces involving the hips of elite athletes place them at potentially higher risk for chondral injuries, labral injuries, or both. Ten patients (13 hips) had arthroscopy. Of the 10 patients, the average age was 24 years. Nine patients were men and one was a woman. Of the 13 (10 patients) arthroscopies done two cases were bilateral, and one patient had the same hip operated on twice. Seven of the patients were professional hockey players, one patient was a football player, one patient was a baseball player, and one patient was a golfer. All 13 hips (10 patients) had anterior labral tears, whereas two hips had anterior and posterior labral tears. Two hips had an average of four loose bodies, four had evidence of chondral lesions, and one had an anterior margin acetabular fracture. Twelve of 13 arthroscopies were successful; however, one patient had recurrent symptoms. There were no surgical complications. Hip arthroscopy is a safe and reproducible method to diagnose and treat intraarticular hip disorders in athletes, which facilitates earlier return to their respective sport.     

髋关节镜的治疗进展

髋关节是人体重要的负重关节,周围有坚强的肌肉保护以及丰富的神经结构,这使得对其病变的诊断及治疗相对困难。常规手术往往会严重损害周围软组织及重要结构,术后出现关节粘连等并发症的可能性较大。随着关节镜器械及技术的发展,髋关节镜的应用近20年得到了迅速发展,其具有切口小,对周围组织神经损伤轻等优点。关节镜对髋关节病变的诊断起到了重要作用,同时还提供了更好的治疗方式。随着设备与技术的改进,MRI在髋关节疾病诊断的广泛应用,关节镜微创治疗逐渐成为髋关节疾病的临床技术之一。     

Incidence of loose bodies in an osteoarthritic hip.

In a prospective study of 75 consecutive primary Charnley low friction arthroplasties carried out for osteoarthritis, loose bodies were found in nine hip joints; an incidence of 12%. Whether their presence is the cause or the effect of the condition remains unclear. Their discoid or spherical shape suggests that they were free and had been subjected to sliding or rolling motion. Those of irregular shape may have remained partly attached within the capsule, or become confined to a space.     

Intraarticular loose bodies in the adolescent hip: results of treatment of those recognized late

Seven cases of intraarticular loose bodies, previously unrecognized, were treated with surgical removal of the fragment. The presence of an intraarticular loose body was suspected because of persistent pain, restriction of hip joint motion, and asymmetric widening of the medial clear space on an anteroposterior (AP) pelvic roentgenogram. The diagnosis was established by computed tomography (CT) scan. Surgical removal should yield a good to excellent result, even when performed late, as long as osteonecrosis is not present at the time of operation.     

Technical pearls for hip arthroscopy in the management of synovial chondromatosis

Synovial chondromatosis of the hip is often underdiagnosed. A high index of suspicion and good quality imaging studies are therefore essential. A wide array of long and curved instrumentation is needed at surgery. Efficient use of time and an organized surgical approach are critical to decrease joint distraction time and potential complications. A successful outcome, with pain relief and return of joint function and range of motion, is predicated on incremental follow-up.     

The role of hip arthroscopy in the evaluation of avascular necrosis

This prospective study evaluated the correlation between plain radiographs, magnetic resonance imaging (MRI), and diagnostic arthroscopy in the staging of avascular necrosis of the femoral head. Fifty-two hips in 46 patients were prospectively staged using radiographic and MRI staging systems. Patients subsequently underwent hip arthroscopy to visualize the articular surface prior to considering salvage of the femoral head and debride delaminated osteochondral fragments. Weighted Kappa analysis revealed only moderate correlation between MRI and plain radiographs (K=.11), MRI and arthroscopy (K=.21), and plain radiographs and arthroscopy (K=.19). Six (46%) of 13 patients with a radiographically apparent subchondral fracture demonstrated collapse of the articular surface at arthroscopy. Four (24%) of 17 hips with >2 mm of collapse of the femoral head on plain radiographs demonstrated fragmentation of the osteochondral surface of the femoral head at arthroscopy. In 5 patients with flattening of the femoral head, 3 patients had delamination of both the femoral and acetabular surfaces. In regard to labral pathology, 5 of 22 post-collapse hips also had large bucket handle tears of the labrum. Arthroscopy of the hip revealed osteochondral degeneration that was not detected by plain radiographs or MRI in 36% of post-collapse femoral heads.     

The efficacy of arthroscopy in the treatment of hip osteoarthritis

We evaluated the utility and the safety of arthroscopy for diagnosing and treating symptoms in patients with osteoarthritis (OA) of the hip. We studied 133 patients consecutively treated for hip OA, using a modified Harris Hip Score (HHS) for the clinical assessment: There were no related complications or infections. At an average follow-up of 18 months, 61% of patients showed an improvement of their preoperative score, although only 36% of those actually presented good or excellent results. The remaining 39% of the total, either developed recurrent symptoms or underwent a major surgical procedure after arthroscopy. Benefit derived from the arthroscopy procedure depends strictly on either age or OA severity. Arthroscopy of the hip joint is a safe tool for managing problems related to OA of the hip. Careful selection of patients must be performed to identify those who will benefit most from the procedure. It seems that young patients with early OA are those associated with a higher rate of procedure success.     

Hyaluronan in synovial fluid of patients with loose total hip prosthesis

The concentration and molecular weight of hyaluronan (HA) in the synovial fluid of the hip joint were determined in 13 patients (aged 62.8 +/- 9.4 years) who had undergone prior total hip arthroplasty(THA), 23 patients (aged 65.0 +/- 8.2 years) with osteoarthritis of the hip joint (OA), and 13 patients (aged 40.2 +/- 2.7 years) with idiopathic osteonecrosis of the femoral head (ION). A sample of synovial fluid was obtained during revision THA because of loosening of the total hip prosthesis for the THA group, and during the first replacement surgery or osteotomy for the OA and ION groups. The concentration of HA in the synovial fluid was 0.64 +/- 0.42 mg/ml in the THA group, 1.07 +/- 0.28 mg/ml in the OA group, and 1.30 +/- 0.56 mg/ml in the ION group. The concentration of HA in the synovial fluid of the THA patients was significantly lower than that of the OA and ION patients (P = 0.0156 vs OA, P = 0.003 vs ION). The molecular weight of HA was 309 +/- 88.3 x 10(4) Da in the THA group, 377 +/- 201 x 10(4) Da in the OA group, and 240 +/- 148 x 10(4) Da in the ION group; these values do not differ significantly (P = 0.259 vs OA, P = 0.174 vs ION). Among the THA patients, there was no relation between the concentration of HA and the age of the patient, length of time since the first operation, or type of prosthesis fixation; there was also no relation between the molecular weight of HA and each of these factors. These results suggest that a pseudosynovial membrane is regenerated after THA, and that it produces HA of the same molecular weight as that in patients with OA and ION, although in smaller quantities.     

Hip arthroscopy for osteochondral loose body removal after a posterior hip dislocation

We report on the application of hip arthroscopy to remove an osteochondral fragment created by a posterior hip dislocation. Preoperative and postoperative radiographs and computed tomography scans correlate with intraoperative arthroscopic photographs and are presented with this report. Arthroscopy allowed excellent visualization of the joint and facilitated straightforward removal of the fragment. We were able to avoid the larger incision required by an arthrotomy and decreased the patient’s overall morbidity from this condition.     

髋关节镜在单纯创伤性髋关节脱位治疗中的应用

目的 探讨髋关节镜技术在单纯创伤性髋关节脱位中的应用价值.方法 2005年8月至2009年1月收治8例单纯创伤性髋关节脱位患者,男7例,女1例;平均年龄36.3岁(18～43岁);左侧3例,右侧5例.受伤至复位时间平均为3 h,复位成功到接受髋关节镜手术时间为2～3周.8例患者均行髋关节镜探查、关节清理、游离体摘除术.术后牵引3周.结果 术中证实8例患者髋关节腔内均存在撕脱的游离体,骨性游离体6例,软骨性2例.8例患者术后获6个月～3年4个月(平均1年2个月)随访.术后6个月髋关节Harris评分平均为(94.4±5.3)分,疗效均为优.无一例患者出现手术并发症或下肢牵引并发症.结论 对于单纯创伤性髋关节脱位,髋关节镜下关节腔清理术可以清除关节内血肿及游离体,手术创伤小、关节功能恢复快,可减少创伤性关节炎的发生.     

The role of midcarpal arthroscopy in the diagnosis of disorders of the wrist.

The findings of midcarpal versus radiocarpal arthroscopic examinations were compared in the diagnosis of a variety of wrist pathology in 89 patients. During 15 months 89 midcarpal arthroscopic examinations were performed in conjunction with radiocarpal arthroscopic examinations. Eighty-one wrists underwent arthroscopy for acute or chronic intracarpal instability. Eight wrists underwent arthroscopy for arthroscopy-assisted intra-articular distal radius fracture reduction. In the acute wrist instability group midcarpal arthroscopy added to the radiocarpal diagnosis in 21 of 26 (82%) of the wrists. In the chronic wrist instability group midcarpal arthroscopy added to the radiocarpal diagnosis in 46 of 55 (84%) of the wrists. In the distal radius group 5 of 8 wrists had additional pathology on the midcarpal arthroscopy examination, leading to additional surgical intervention. These results demonstrate that midcarpal arthroscopy added statistically significant information to the radiocarpal examination compared with wrist arthroscopy performed without a midcarpal examination.     

髋关节镜治疗股骨髋臼撞击征的研究进展

股骨髋臼撞击征是近10余年才被逐渐认识的一种髋关节疾病,也是年轻人髋部疼痛的常见病因之一,其会导致髋关节运动过程中异常应力接触,这种病理力学机制与早期骨关节炎的发展密切相关。手术本身主要针对于病因进行治疗。随着关节镜技术和可折弯器械的发展,髋关节镜运用得越来越广泛,患者创伤小、术后康复较快且并发症发生率较低,短期和中期的效果令人满意,单纯盂唇修复的效果也优于单纯清理术,但是这些尚需要长期和大样本量的结果来进行随访。     

The role of arthroscopy in the management of synovial chondromatosis of the shoulder. A case report

A case of synovial chondromatosis of the shoulder is reported in a 28-year-old man with long-standing shoulder pain after a remote episode of trauma. Although plain roentgenograms were normal, arthrograms revealed the characteristic findings of synovial chondromatosis. Treatment consisted of arthroscopic removal of multiple cartilaginous loose bodies and partial synovectomy. Synovial chondromatosis of the shoulder treated with arthroscopic debridement and synovectomy rather than traditional open arthrotomy seems not to have been reported previously.     

Failed hip arthroscopy: causes and treatment options

Indications for arthroscopic surgery of the hip have increased over the past several years, along with the number of procedures performed annually. In addition, the number of unsuccessful procedures and subsequent revision surgeries have also increased. Recent literature has defined several common causes for failed hip arthroscopy. Severe osteoarthritis and osteonecrosis are associated with poor outcomes. Findings during revision hip arthroscopy consistently demonstrate untreated femoroacetabular impingement, chondral defects, labral tears, and postoperative adhesions. The treating surgeon must be diligent in his or her indications for surgery, as well as in addressing all pathology at the initial surgery.     

The classification of loose bodies in human joints

A histopathological analysis of 119 surgically excised loose bodies revealed that the cases could be separated into three categories: (1) loose bodies due to synovial osteochondromatosis; (2) loose bodies due to osteochondral fracture; (3) loose bodies due to joint surface disintegration. Three different types of cartilage were identified in the nidus of a loose body--articular, osteophytic, and lobular. Attached bone could be seen from any of the three types of loose bodies but was rare in those specimens secondary to synovial osteochondromatosis. Three mechanisms for the generation of loose bodies in cases of degenerative arthritis or avascular necrosis are proposed: (1) fragmentation of the joint surface; (2) fractured osteophytes; (3) osteochondral nodule proliferation in the pararticular soft tissues. Correlation of the gross and microscopic pathology with the clinical history, roentgenograms and surgical findings usually resulted in a comprehensive understanding of the pathogenesis of any particular case.