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This article reviews the anatomy of synovial-lined structures around the knee joint including the joint capsule, plicae, bursae, and tendon sheaths. Pathologic conditions are grouped into either inflammatory, induced by deposition of various substances, or neoplastic. The MRI appearances of the various diseases are discussed.
Using bone organ culture techniques, we studied the production of bone-resorption stimulating factors by the different tissues surrounding loosened total hip arthroplasties. Revision arthroplasties were performed in 13 patients. Various periprosthetic tissues were obtained from these patients. Culture media conditioned by the newly formed capsules contained higher bone-resorption activity when compared to the resorptive activity found in media conditioned by bone-cement membranes. Addition of indomethacin or structurally unrelated non-steroidal anti-inflammatory drugs, or corticosteroids, to bone-cement membrane cultures altered the process of bone resorption in the vicinity of cemented joint implants suggesting that both prostaglandin and other mediators may be involved in the mechanism by which bone-resorbing osteoclasts are stimulated. Our observations indicate that, in the sequence of events that leads to loosening of implants, mediators released from the joint capsules may be more important than those produced by the bone-cement membranes.
To reduce the disability after hip disarticulation, we developed a special surgical procedure in patients having a proximal femoral tumor with a large tumor involving the sciatic nerve or neoplasms involving the tibia and femur. The hip was disarticulated, but we preserved a musculocutaneous flap. A modular endoprosthesis was then placed in the acetabulum or, in case of an extraarticular resection of the hip joint, it was placed in the iliac bone. A trevira tube was used for reconstruction of the joint capsule and fixation of soft tissues. We performed this procedure in 5 patients who had a good functional outcome.
Inflammation at the insertions of ligaments, tendons, or joint capsules to bone, which is termed enthesitis, is a characteristic feature of spondyloarthropathy. Because of the relative inaccessibility of the enthesis, the inflammatory, microbiologic, and immunologic events at that site have been poorly defined. Recent magnetic resonance imaging studies have drawn attention to the ubiquitous nature of enthesitis in spondyloarthropathies, especially adjacent to synovial joints. This may have implications for the mechanisms of synovitis in spondyloarthropathies. Magnetic resonance imaging studies also suggest that enthesitis lesions may be extensive, which could explain the diffuse nature of bone changes seen in some patients with spondyloarthropathies. The importance of enthesitis as a skeletal phenomenon in spondyloarthropathies has gained further support from transgenic models in which either tumor necrosis factor-alpha or bone morphogenetic protein-6 overexpression result in entheseal-associated polyarthropathy.
The rotator interval and the long head of the biceps brachii tendon are anatomically closely associated structures believed to confer stability to the shoulder joint. Abnormalities of the rotator interval may be acquired or congenital and are associated with instability of the long head of the biceps brachii tendon. Clinical and arthroscopic diagnoses of rotator interval abnormalities and subtle instability patterns of the long head of the biceps brachii tendon are difficult. Magnetic resonance arthrography, owing to its superior depiction of ligaments with distention of the joint capsule, may be the procedure of choice, barring open surgery, for help in diagnosis of these conditions.
One complication of the Chrisman-Snook ankle reconstruction is persistent postoperative pain. The incidence of this complication ranges from 7% to 60%. We report 10 cases of surgical exploration for persistent pain after Chrisman-Snook reconstructions. In 6 of the 10 cases a surgically correctable cause was found for the pain. The identified pathologic lesions in these 6 patients could have been prevented by careful attention to detail in the index operation. Surgical exploration should be considered for any of the following findings: persistent point tenderness (especially at the graft tunnel sites), localized swelling, a painful mass, recurrent instability/laxity, a symptomatic neuroma, or painful inversion and dorsiflexion. To prevent the complication of persistent postoperative pain after the Chrisman-Snook ankle reconstruction, we recommend the following: 1) avoid forced eversion when tensioning the graft, excessive posterior placement of the calcaneal tunnel, casting in eversion, and the use of nonabsorbable suture; 2) resect the distal muscle belly of the peroneus brevis muscle distal to the superior peroneal retinaculum; 3) check for tears in the peroneus brevis; 4) respect the sural nerve; and 5) obtain a watertight closure of the joint capsule. Although the Chrisman-Snook ankle reconstruction is an excellent technique, numerous pitfalls in surgical technique must be avoided.
UNLABELLED: The aim of the study was to analyze the type and incidence of major and minor complications resulting from arthroscopy with arthroscopic synovectomy of the knee joint performed by rheumatologist in different rheumatological diseases. METHODS: In a prospective study the incidence of complications in arthroscopic subtotal synovectomy with subsequent tidal flow lavage was analyzed in 201 rheumatic patients. The arthroscopic synovectomies were performed by one team of rheumatologists in the operation room of the University Clinic of Rheumatology in the town of Plovdiv for a period of 8-9 years. RESULTS: The major complications related to the arthroscopic synovectomy included septic arthritis (0.5%) and rupture of the joint capsule with edema of the thigh and leg (1.5%). The minor postarthroscopic complications were infection of the operative skin incision (2.0%), hemarthrosis (3.5%), severe postoperative pain (1.5%) and gout relapse (0.5%). Complete recovery was achieved after complications were treated and the result of the synovectomy was not compromised. CONCLUSION: Arthroscopic synovectomy of the knee joint performed by rheumatologist in in-patients involves low risk of complications among which minor operative and postoperative ones are prevalent. These do not compromise near and late results of the arthroscopic synovectomy.
The clinical and radiographic appearance and histological findings in three cats with cystic extensions of the elbow joint capsule are described. The condition was only temporarily alleviated by surgical excision or drainage. In all cases the condition was associated with osteoarthritis.
A study of the attachment of the joint capsule to the scapula, and of the shape of the humeral head, has been carried out in 52 fetal and embryonic shoulders. In 77% of cases the anterior capsule was attached to the labrum or close to it; in the remaining 23% it was inserted into the neck of the scapula, so creating a pouch. In all 52 specimens the humeral head was spherical. It was concluded that the pouched and redundant anterior capsule sometimes seen during surgery for recurrent dislocation of the shoulder, may not be traumatic in origin, but could be a developmental variant.
High-resolution real-time sonography not only provides a noninvasive means of diagnosing hip effusions, but also provides easy access for arthrocentesis. Nineteen sonographically guided hip arthrocentesis were performed in 18 patients. In 13 of 19 patients aspirated, capsular distension was present. In 10 of 19 patients, fluid could be aspirated from the joint space (volume varying from 1 to 9 mL). Saline lavage was performed in 12 of the 19 joints needled. Intra-articular location was confirmed by observation during distension on real-time images or by successful aspiration. Sonographically guided arthrocentesis has potential advantages over conventional fluoroscopic techniques. These include a lack of ionizing radiation, superior visualization of needle location within the joint capsule, and the ability to diagnose soft tissue and periarticular abnormalities generally not seen fluoroscopically.
The authors describe a case of intra-articular nodular fasciitis of the knee in a 49-year-old man. The lesion arose from the posterior joint capsule of the knee and protruded into the femoral intercondylar notch. Histologic findings of the excised lesion were consistent with those of nodular fasciitis. Immunohistochemical and electron microscopic studies revealed a myofibroblastic proliferation. Surgical excision of the lesion was curative. A careful search of the literature revealed no case in which nodular fasciitis occurred in a joint in the extremities.
Electrical stimulation of group II joint afferents of the posterior articular nerve (PAN) to the knee evoked short-latency facilitation and/or inhibition of the background discharge of gastrocnemius-soleus (GS) gamma-motoneurones in decerebrated spinal cats. The latencies of these responses were consistent with mediation via segmental oligosynaptic spinal pathways. In addition, a longer-latency facilitation was frequently observed. Mechanical non-noxious stimulation of the skin within the field of innervation of the sural nerve, on the lateral aspect of the heel, suppressed the short-latency facilitation, but not the inhibition or long-latency facilitation. Brief mechanical indentation of the posterior aspect of the knee joint capsule could elicit facilitation or inhibition of gamma-motoneurones. Facilitation, but not inhibition, was blocked by anaesthesia or section of the PAN. Both actions could be suppressed by mechanical stimulation of the heel. We conclude that GS gamma-motoneurones receive both facilitatory and inhibitory segmental inputs from group II articular afferents arising in the knee joint. Cutaneous afferents from the sural field exert a selective inhibitory influence over the facilitation of fusimotor discharge by articular afferents.
From 1978 to 1991, the platysma myocutaneous flap of different designs was used to treat 69 patients with tumor extirpation defects of temporomandibular ankylosis. The conventional platysma myocutaneous flap was used to repair buccal defects. The combined platysma and sternocleidomastoid myocutaneous flap was used to reconstruct the tongue and the floor of the mouth. The innovated platysma myocutaneous flap, i.e. folded platysma myocutaneous flap was used to reconstruct the temporomandibular joint capsule for true ankylosis. All the procedure was completed in one stage and the operative results were satisfactory.
The cases of 14 patients seen 6 weeks to 7 years after gunshot wounds with painful, restrictive joint disease and retained intra-articular bullets were reviewed. Twelve patients had radiographic findings characteristic of lead synovitis. The earliest finding was a fine, punctate deposition of radiopaque lead on the articular cartilage that resembled chondrocalcinosis but was of greater density. This was followed by more discrete lead speckling of hypertrophied synovium. The opacities became larger, coarser, and more confluent over time, ultimately outlining the synovium, articular cartilage, and joint capsule. Synovial hypertrophy and diffuse chronic inflammation and fibrosis were seen in seven patients on gross pathologic examination. The lead was deposited extracellularly in the subsynovial layer and within the marrow spaces of subarticular and periarticular bone. Electron-microscopic study suggests that lead is initially incorporated within cells and secondarily deposited extracellularly after cell death. Bullets in joints are not physiologically inert and should be removed when encountered.
The Garlicki-Salamon method consists in isolation of the patella ligaments, loosening of the lateral pulleys, medial and downward transposition of the patella ligament insertion, wrapping of the medial joint capsule, and transfer of the m. vastus medialis insertion to the medial-upper quadrant of the patella. The late follow-up (at least 5 years of observation) was carried on in 26 knees. 4 results were excellent, 10 -- good, 8 -- fair, 4 -- poor. In nine cases (35 per cent) development osteoarthritis of the patello-femoral joint was found. Recurrence of dislocation was found in 4 cases.
An imaging-anatomic correlative study of ankle anatomy based upon six healthy adults and six fresh cadaveric specimens was performed to evaluate the diagnostic capabilities of magnetic resonance imaging (MRI). Optimal pulsing sequences and imaging planes for various structures of interest were established. MRI afforded exquisite depiction of anatomic detail, particularly the diagnostically important collateral ligaments. Limitations in the ability to delineate the joint capsule and articular cartilage were documented, with the former detectable only on T2 weighted images in the presence of synovial fluid.
Synovial chondromatosis is characterized by formation of cartilaginous nodes, possibly with ossification, in the synovial membrane of the joints, tendons, and vagina. The description of a case of synovial chondromatosis located in the knee joint capsule is presented. Histologically, apart from hyaline cartilage resembling chondroma the areas simulating chondrosarcoma were found. The differential diagnosis between synovial chondromatosis and chondrosarcoma is proposed.
This study was designed to examine the roles of ligaments in the maintenance of the articular kinematics of the trapeziometacarpal joint. Circumduction of the trapeziometacarpal joint was studied in 12 hands from fresh human cadavera. With use of a magnetic tracking system, changes in the motion of the base of the first metacarpal after ligament sectioning were analyzed and compared with those of the normal joint. Two sets of ligaments were sectioned: (a) the anterior oblique and ulnar collateral ligaments and (b) the first intermetacarpal ligament and the ulnar joint capsule. Sectioning of the anterior oblique and ulnar collateral ligaments resulted in a significant dorsal-ulnar shift in the path of the base of the first metacarpal. However, sectioning of the first intermetacarpal ligament did not affect the movement pattern of the center of the base. The anterior oblique and ulnar collateral ligaments provided constraint of the trapeziometacarpal joint during circumduction of the thumb.