Robert G. Gray

Diagnostic and therapeutic uses of the arthroscope in rheumatoid arthritis and osteoarthritis

Both the technique and the technology involved in knee arthroscopy have undergone considerable development over the last 10 years. Diagnostically, the procedure allows visualization of synovium, hyaline cartilage, fibrocartilage (menisci), and ligaments (cruciate, patellofemoral alignment). Synovitis of rheumatoid arthritis is suspected by boggy, hyperemic, and edematous hypervilli that may undergo necrosis. In osteoarthritis, the synovium is often mildly inflamed and the cartilage demonstrates ulcerations, yellowing, softening, and areas of denuded bone. Synovectomy for rheumatoid arthritis was first performed about 1900. The apparent reduction in morbidity resulting from performing synovectomy through the arthroscope accounts for the resurgence of interest in this procedure. Removal of loose bodies, fragments of cartilage, or synovium helps to reduce synovitis and symptoms in both rheumatoid arthritis and osteoarthritis. Shaving of articular cartilage is often performed in patients with osteoarthritis. There is a suggestion that coring or shaving osteoarthritic denuded bone stimulates repair of a type of fibrocartilage that may be functional. Surgical technology and technique in the field of arthroscopy are advancing faster than the clinical studies necessary to prove their value. Guidelines for the use of these potentially destructive techniques are still needed. Arthroscopy is a rapidly developing field in medicine. The next 10 years will almost assuredly provide enhanced diagnostic and surgical capabilities with reduced morbidity in the rheumatic diseases, and particularly in rheumatoid arthritis and osteoarthritis.

Primary Familial Bilateral Carpal Tunnel Syndrome

We identified bilateral carpal tunnel syndrome in 19 of 43 living persons of a nonconsanguineous family. No single common etiologic feature was seen. Sixty-three percent of the afflicted kindred had symptomatic digital flexor tenosynovitis. Noninflammatory thickening of the flexor retinaculum or tendon sheaths, or both, was the commonest surgical finding. The 44% prevalence, early age of onset, and equal sex ratio differ from idiopathic carpal tunnel syndrome. Family pedigree suggests an inheritable disorder transmitted by an autosomal dominant gene with a high degree of penetrance.