Synovial Abnormalities

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The synovium can be the genesis of deep-seated and unremitting hip joint pain. A diverse number of etiologies may initiate synovial irritation. These conditions may be of inflammatory, hematologic, crystalline, collagen disease, mechanical, viral, or tumorous origin. Specific treatment is based upon whether the condition is focal or diffuse, and self-limiting or unremitting in nature. Crystalline diseases such as gout or pseudogout can produce extreme hip joint pain. A joint effusion, best seen on T2 weighted MR scanning, can be accompanied by an elevated or normal serum uric acid level. Joint fluid analysis with polarized-light microscopic verification clinches the diagnosis. At arthroscopy the senior author has witnessed high concentrations of crystals diffusely distributed throughout the synovium as well as embedded within the articular cartilage of the acetabulum. (Figure 6.6.) Arthroscopic treatment consists of copious lavage, mechanical removal of crystals, and synovial biopsy if necessary.

Collagen diseases such as JRA, rheumatoid arthritis, lupus erythematosus and Ehler-Danlos not only occur in the hip, but this may be the presenting symptomatic joint. Rheumatoid arthritis may present with an effusion, dense synovitis synchiae, and synovial cysts, as well as articular surface damage. Intense joint pain unresponsive to extensive conservative measures is the rationale for arthroscopic intervention. The senior author has observed synovitis so hypertrophic and hy-peremic that it obscured initial visualization of the femoral head and acetabulum. Arthroscopic treatment consists of synovial biopsy and/or synovectomy, evaluation and treatment of accompanying articular cartilage damage, and lavage. Procedural results are directly dependent on the stage of articular surface involvement.

Ehler-Danlos syndrome, as in the shoulder joint, may present with pain and instability. In combination with medical diagnosis, arthroscopic treatment has consisted of skin and synovial biopsy to further define the disease classification. In addition, thermal capsular shrinkage has been performed judiciously. The senior author's experience to date has been uniformly favorable. Longer-term follow-up is requisite to define this procedure's ultimate utility.

Synovial chondromatosis is a metaplastic synovial condition that results in the production of numerous loose bodies. Although benign, this tumorous entity may be recurrent. The loose bodies, when non-ossified, can make diagnosis of this disease extremely difficult. The senior author has reported in 20 cases preoperative diagnosis by all radiographic means was established in only 50% of patients, and all of these hips had calcified bodies present. None of the cases with non-ossified bodies were evident before surgery, even with MR scanning.12 Arthroscopic treatment in 20 cases to date has consisted of classification of diagnosis, removal of between 5 and 300 loose bodies especially those clustered within the fovea, treatment of articular damage, and synovectomy. (Figure 6.7.) Although recurrence may occur despite intervention—in the author's experience the rate is 10%—a second arthroscopy may be performed without intercedent scarring. In addition ar-throscopy, in contrast to open arthrotomy, has been executed without the attendant risks of osteonecrosis, heterotopic bone, deep vein thrombophlebitis, neurovascular injury, or infection. (See Chapter 14.)

Hematologic disorders such as sickle cell anemia, hemophilia, and pigmented villonodular synovitis can produce significant joint symptoms. Although medical management is usually effective, arthroscopic intervention may be warranted when dysfunction becomes protracted. This minimally inva

Figure 6.7. Chondral loose bodies clustered within the fovea in synovial chondromatosis.

sive approach has much less bleeding risk than open arthro-tomy. Surgical treatment includes evacuation of hematoma, removal of synechiae, copious lavage, and synovectomy as necessary. There is no outcome data on this procedure, however symptomatically beneficial, to date.

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