Darrell Ogilvie-Harris

Pigmented villonodular synovitis of the knee. The results of total arthroscopic synovectomy, partial, arthroscopic synovectomy, and arthroscopic local excision.

Twenty-five patients who had had a diagnosis of pigmented villonodular synovitis of the knee were followed for an average of four and one-half years (range, two to ten years) after arthroscopic treatment. Five patients had had localized lesions and had been managed with local resection; all five had improvement, with no apparent recurrence. The remaining twenty patients had had diffuse disease. Of these twenty, eleven had had a complete arthroscopic synovectomy. All eleven had definite improvement in pain and function, and almost all had a decrease in synovitis and an increase in the range of motion of the knee; the disease recurred in only one. The other nine patients had had a partial arthroscopic synovectomy. Although most had some improvement in function and range of motion and a decrease in pain and synovitis, the disease recurred in five of the nine. Thus, in the patients who had had diffuse pigmented villonodular synovitis, the rate of recurrence was lower in those who had had a complete arthroscopic synovectomy than in those who had had a partial arthroscopic synovectomy (p = 0.01).

The resistant frozen shoulder. Manipulation versus arthroscopic release.

Frozen shoulder is often a self-limited disease, but approximately 10% of patients have long-term problems. Arthroscopy was done in 40 patients with persistent pain, stiffness, and functional loss for at least 1 year without improvement despite conventional treatment. In the first 20 patients, manipulation was done with an arthroscopy before and afterward; in the second 20 patients, the contracted structures were divided through arthroscopy. This was a prospective cohort study; 2 patients were not available for followup. The arthroscopic division procedure was done in 4 sequential steps: (1) resection of the inflammatory synovium in the interval area between the subscapularis and supraspinatus; (2) progressive division of the anterior superior gleno-humeral ligament and anterior capsule; (3) division of the subscapularis tendon but not muscle; and (4) division of the inferior capsule. The results were assessed independently on the basis of pain, stiffness, and function. The followup varied from 2 to 5 years after intervention. Patients treated with arthroscopy and manipulation did as well as the patients treated with arthroscopic division for restoration of range of movement. However, the patients in the arthroscopic division group had significantly better pain relief and restoration of function. Fifteen of 20 patients treated with arthroscopic division had an excellent result compared with 7 of 18 patients treated with arthroscopy and manipulation. Patients with diabetes did worse initially, but the outcome was similar to patients without diabetes. Patients with diabetes in particular may benefit from early intervention.

Disruption of the ankle syndesmosis: Diagnosis and treatment by arthroscopic surgery

Over a 10-year period, 19 patients were seen who had the clinical features of disruption of the syndesmotic ligaments of the ankle. Seventeen of these were available for follow-up by history and 13 by physical examination. The patients underwent an arthroscopy for persistent symptoms an average of 2 years following the injury. Preoperatively the patients had a positive external rotation stress test. A triad of pathological features was found: disruption of the posterior inferior tibiofibular ligament; rupture of the interosseous ligament; and chondral fracture of the posterolateral portion of the tibial plafond. Arthroscopic resection of the torn portion of the interosseous ligament and the chondral pathology successfully relieved the symptoms in most of the patients. There was a statistically significant improvement in pain, swelling, stiffness, stability, limp, and activity levels. The external rotation stress test was converted to negative. Patients with persistent pain following a syndesmotic disruption of the ankle can benefit substantially by removal of the intraarticular pathology associated with such injuries. Residual instability of the syndesmosis itself did not seem to be a problem.

Arthroscopic management of the degenerative knee

Out of a total 551 arthroscopic procedures for degenerative arthritis of the knee, 441 were studied at 2-8 years following their procedure. Sixty-eight percent of patients had at least 2 years or more relief of pain and symptoms. Fifty-three percent were still good at follow-up of 4.1 years. The best results were obtained after resection of an unstable flap tear of a meniscus in association with mild degenerative arthritis. The worst results were obtained in patients with bicondylar disease and in the presence of chondrocalcinosis. The results were much better in the normally aligned knee; the valgus knee did worst. Repeated arthroscopic procedures have a much lower success rate.

Disruption of the ankle syndesmosis: Biomechanical study of the ligamentous restraints

We investigated the relative importance to stability of the four component ligaments of the distal tibiofibular syndesmosis. Eight fresh-frozen cadaver specimens were tested on a hydraulic test system during sequential cutting of the ligaments. The percentage resistance to 2 mm of diastasis was measured for the four ligaments. The anterior inferior tibiofibular ligament provided 35%, interosseous ligament 22%, superficial posterior inferior tibiofibular 9%, and deep posterior inferior tibiofibular 33%. These results have clinical implications with regard to injury. Damage to the syndesmosis should be assessed anteriorly and posteriorly at the time of examination. The interosseous ligament can be visualized arthroscopically.

Anterior impingement of the ankle treated by arthroscopic removal of bony spurs

We reviewed 17 patients after arthroscopic resection for anterior impingement in the ankle. All had had painful limitation of dorsiflexion which had failed to respond to conservative treatment. Review at an average of 39 months showed very significant improvements in levels of pain, swelling, stiffness, limping and activity. There was a significant improvement in the range of dorsiflexion but not of plantar flexion. One poor result was due to a superficial infection, and two other patients had residual numbness of the foot which persisted for several months.

Septic arthritis following arthroscopy, with cost/benefit analysis of antibiotic prophylaxis

Nine cases of septic arthritis following arthroscopy are reviewed retrospectively. All cases of septic arthritis followed arthroscopic surgery. The average age of the patients was 49 years. The diagnosis was confirmed by bacterial cultures of the joint aspirates. All cases were treated by appropriate antibiotics supplemented by repeat arthroscopy and placement of a suction irrigation system. The average stay in hospital was 21 days. The authors suggest that it is not possible to predict such a major complication based on risk factors and therefore present a cost/benefit analysis of antibiotic prophylaxis using first-generation cephalosporins as a possible means of reducing hospital costs and patient morbidity.

Chronic pain following ankle sprains in athletes: The role of arthroscopic surgery

We reviewed 100 patients treated arthroscopically for symptoms of chronic ankle pain associated with sprains of the ankle. All had pain that had failed to respond to conservative treatment for at least 6 months. The pathology in 95 of the 100 ankles studied could be categorized into one of three groups: the instabilities (lateral and syndesmotic), the impingements (anterior and anterolateral), and articular lesions (chondral and osteochondral). Five patients had nonspecific osteoarthritis and/or synovitis on arthroscopy. Patients were followed-up for improvements in six categories: pain, swelling, stiffness, limping, activity, and instability. The primary outcomes of pain and activity were analyzed statistically. Patient satisfaction and return to sports were evaluated. Significant improvements were obtained for patients treated for syndesmotic instability, and anterior and anterolateral impingement. Chondral fractures in the presence of a stable ankle had good results in 75% of cases, compared with those in unstable ankles with only 33% good results. Osteochondritis dissecans was treated successfully by excision of the lesion and abrasion of the base. Patients with chronic lateral instability were treated by open repair, so only the diagnostic arthroscopic findings are reported. We concluded that arthroscopy offered little to the management of lateral instability unless there was considerable doubt regarding the diagnosis. There were minimal improvements for the patients with nonspecific diagnoses such as posttraumatic synovitis. Ankle arthroscopy may be a very useful diagnostic and therapeutic tool in patients who have not responded to conservative therapy.

The diabetic frozen shoulder: Arthroscopic release

Seventeen patients who were diabetics developed frozen shoulders which failed to respond to conservative management. They had persistent pain, stiffness, and limited function. An arthroscopic release was performed by progressively releasing the anterior structures from superior to inferior. Starting from the interval area we progressed to the anterior superior glenohumeral ligament, the intra-articular portion of the subscapularis, the anterior capsule, and the inferior capsule. Postoperatively physiotherapy was carried out daily to maintain the range of movement. At a follow up of 1 to 5 years the patients were assessed using the American Shoulder Society scheme. In addition the patients were assessed preoperatively and postoperatively on four criteria; pain, external rotation, abduction, and function. We found that the patients were statistically significantly improved in all four categories. Thirteen of the 17 patients had no pain, full range of motion compared with the opposite side, and full function. There was one poor result with no improvement. The remaining three patients had improved but still had residual abnormalities. We consider arthroscopic release to be an effective treatment for the resistant diabetic frozen shoulder.

Generalized synovial chondromatosis of the knee: A comparison of removal of the loose bodies alone with arthroscopic synovectomy

Thirteen patients with generalized synovial chondromatosis of the knee were treated by either removal of the loose bodies alone (n = 5) or arthroscopic synovectomy (n = 8). The average follow-up was 38 months (range 23-61). There were three recurrences in the loose body removal group, which were subsequently treated by arthroscopic synovectomy. Statistical analysis of the results shows a significant improvement in pain, synovitis and effusion, range of movement, and function after either treatment. The group treated by arthroscopic synovectomy had significantly lower recurrence rates (p = 0.02). We recommend arthroscopic synovectomy for patients with generalized synovial chondromatosis. However, if loose bodies alone are removed, a recurrence can be successfully treated by an arthroscopic synovectomy.