Synovial Disease

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As with other joints, arthroscopic synovectomy has a recognized role in the hip. A variety of synovial disorders may be addressed, including various inflammatory arthritides and miscellaneous synovial conditions such as synovial osteochondromatosis, pig-mented villonodular synovitis, and possibly hemophiliac arthropathy.54

Synovial lesions of the hip may demonstrate either a focal or a diffuse pattern. Focal lesions emanate from the pulvinar of the acetabular fossa. The pulvinar normally consists of adipose tissue covered by synovium that resides above the ligamentum teres within the fossa. Lesions in this area are sometimes quite painful and respond remarkably well to arthroscopic debride-ment. In this author's estimation, the pulvinar is the neural equivalent of the fat pad in the knee. The tissue seems to be quite sensitive, and lesions of this area are painful. The diffuse pattern involves the synovial lining of the capsule. An adequate synovectomy of this area necessitates arthroscopy of the peripheral compartment.55 The synovectomy is still subtotal, but is at least as complete as can be achieved by any technique other than dislocating the hip in association with an open approach. Gondolph-Zink et al. have described a technique of semiarthroscopic synovectomy, but this procedure offers no advantage over arthros-copy that addresses both the intraarticular and peripheral compartments.56

Rheumatoid arthritis represents the most commonly encountered inflammatory arthritis. Synovec-tomy is indicated in the presence of disabling pain unresponsive to conservative measures including activity modification, physical therapy, and intraarticu-lar injections. Significant symptomatic improvement has been noted even in the presence of advanced radiographic changes. However, in general, the extent of

FIGURE 2.15. A 56-year-old woman with a 6-month history of progressively worsening right hip pain. (A) AP radiograph demonstrates minimal features of osteoarthritis. The superior joint space is relatively well preserved, while subtle evidence of medial space narrowing (arrows) is identified. (B) Arthro-scopic view of the medial portion of the joint reveals diffuse erosive articular loss of the medial femoral head (arrows). (C) Viewing from the anterior portal, the lateral articular surface of both the femoral head and acetabulum are intact (left side), while a line of demarcation (arrows) is evident with the adjoining articular erosion (asterisk) of the medial acetabulum.

FIGURE 2.15. A 56-year-old woman with a 6-month history of progressively worsening right hip pain. (A) AP radiograph demonstrates minimal features of osteoarthritis. The superior joint space is relatively well preserved, while subtle evidence of medial space narrowing (arrows) is identified. (B) Arthro-scopic view of the medial portion of the joint reveals diffuse erosive articular loss of the medial femoral head (arrows). (C) Viewing from the anterior portal, the lateral articular surface of both the femoral head and acetabulum are intact (left side), while a line of demarcation (arrows) is evident with the adjoining articular erosion (asterisk) of the medial acetabulum.

Hip Superior Joint Space Loss

accompanying articular surface damage is usually an indicator of the likely success of arthroscopy.

It is important to be aware that radiographic evidence of joint space preservation may belie the presence of advanced articular surface damage. Arthro-scopic inspection has discerned the presence of this advanced damage in cases of disabling hip pain unexplained by seemingly healthy radiographs. This potential discrepancy between radiographic findings and the extent of joint deterioration is important to consider. In these circumstances, the results of arthros-copy may be poor, but information is gained to explain the disproportionate symptoms. Definitive treatment such as with a total hip arthroplasty is then recognized as an option.

Hajdu57 developed a classification system for soft tissue tumors based on the tissue of origin. Tumors of tendosynovial tissue seem to have the greatest predilection for the hip and include synovial chon-dromatosis and pigmented villonodular synovitis.58

Milgram has described three phases of synovial chondromatosis based on a temporal sequence.59 During phase I, the synovial disease is active but no loose bodies are yet present. The second phase is transitional, in which there is active synovial proliferation and loose bodies are present. During the third phase, the synovium becomes quiescent with no demonstrable disease, but the loose bodies remain. Because of the insidious nature of the disease, by the time symptoms become significant enough to incite diagnosis

Pulvinar Tissue Acetabulum

FIGURE 2.16. A 59-year-old man with a painful left hip. (A) AP ra- verted labrum (arrow) with associated diffuse articular wear of the diograph shows moderate osteoarthritis. (B) Arthroscopic view il- acetabulum (A) and femoral head (F). (B, from Byrd,34 with permis-lustrates a probe entered through the capsule (C) defining an in- sion of Arthroscopy.)

FIGURE 2.16. A 59-year-old man with a painful left hip. (A) AP ra- verted labrum (arrow) with associated diffuse articular wear of the diograph shows moderate osteoarthritis. (B) Arthroscopic view il- acetabulum (A) and femoral head (F). (B, from Byrd,34 with permis-lustrates a probe entered through the capsule (C) defining an in- sion of Arthroscopy.)

and surgical intervention, the synovial process has usually long since receded, leaving behind only the loose bodies to create symptoms. Thus, the histologic diagnosis is often in limbo unless synovium can be identified actively producing loose bodies. Recurrence of disease is possible, but recurrence of symptoms following arthroscopy is usually more accurately the result of residual disease because it can be difficult to ensure that an absolutely thorough debridement has been performed.

The hip is surpassed only by the knee and the elbow as the site of involvement of synovial chondro-matosis.60,61 However, in the hip, the diagnosis is often much more elusive. The loose bodies may be small and entirely radiolucent. In the study by McCarthy et al., at least half these cases were unrecognized before arthroscopy.4

Pigmented villonodular synovitis has been reported in both a nodular and diffuse pattern.62 The hip is the second most frequent site of involvement of this disease, with both patterns having been encoun-tered.61,63 Synovectomy has been proposed as the treatment of choice for patients with preserved articular cartilage.64 The nodular pattern presents as more discrete lesions and can be completely resected with greater reliability. The diffuse pattern requires a much more extensive synovectomy. A generous synovec-tomy can still be accomplished arthroscopically with less surgical morbidity than an open procedure.

Hemophiliac arthropathy rarely involves the hip. In other joints, synovectomy has been used for the treatment of recurrent bleeds and early degenerative changes, but this has not been recommended for the hip.65 The reluctance regarding surgical intervention in the hip may be due to the presence of fibrosis or the potential morbidity of an open synovectomy in this population. Arthroscopy may offer a less invasive approach, but this role has not yet been explored for this disease.

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