Osteochondritis dissecans of the temporomandibular joint: a scoping review

PURPOSE

To perform a scoping review to identify the available evidence regarding osteochondritis dissecans (OCD) of the temporomandibular joint (TMJ).

METHODS

An electronic search of the PubMed, Web of Science and Scopus databases was performed using the following terms: 'Temporomandibular Joint Disorders', 'Osteochondritis Dissecans', 'Joint Loose Bodies' and 'Temporomandibular Joint'. Full-text articles were obtained from the records after applying the inclusion/exclusion criteria.

RESULTS

Ten articles were included in the analysis - six case reports, one case series, one retrospective study, one comparative study and one correlational study - with a total of 39 patients. The most frequently reported clinical presentation involved TMJ pain, locked jaw and articular noises (clicking and crepitus). The imaging methods used to identify OCD were radiographs, tomography, arthrography and magnetic resonance imaging. The reported imaging findings varied widely, but the most frequent were (single or multiple) calcified intra-articular loose bodies, signs of degenerative osseous changes, disc displacements, widening of the joint space and alterations in condylar morphology. Seven articles reported treatments (surgical or conservative), but the treatment outcome was not reported in all of the articles, which makes it difficult to make comparisons.

CONCLUSION

OCD of the TMJ may present various non-specific clinical characteristics, and given the heterogeneous imaging findings, multiplanar images are required for an accurate diagnosis. Finally, the results do not allow recommending a standard treatment for OCD of the TMJ.

Primary Distal Interphalangeal Joint Tenosynovial Chondromatosis of the Small Finger: A Case Report With Literature Review

Primary synovial chondromatosis is a rare, benign proliferative disease of the joint synovium, tenosynovium, or bursal lining, in which cartilage metaplasia leads to the development of multiple intra-articular and periarticular loose osteocartilaginous bodies. This disease usually involves larger joints (knee, hip, elbow, and shoulder), but it has also rarely been reported in the hand. Patients with this disease complain of pain, swelling, nodules, and decreased range of motion of the affected joint. Due to its nonspecific symptoms and low prevalence, this disease often goes misdiagnosed, leading to delays in patient treatment. In the literature to date, there are only a few reports of primary synovial chondromatosis. In this case report, we present a patient with a rare case of primary synovial chondromatosis localized to right small finger distal interphalangeal joint.

Intra-articular loose bodies: a clinico-radiological conundrum with distinctive pathological morphologies

No abstract available.

A case of Candida septic arthritis with rice body formation in a 2-month-old infant

We present a case of rice body formation in the left knee joint of a 2-month-old infant affected by Candida albicans septic arthritis which has never been reported before. Rice body formation has been described in association with rheumatoid or tuberculous arthritis and is very rare in Candida arthritis. After three weeks of therapy with amphotericin B administered intravenously, the infant recovered fully from infection. Septic arthritis is a serious cause of morbidity and for proper evaluation and treatment fungal septic arthritis should be included in the differential diagnosis.

Correlation between MRI and hip arthroscopy in children with Legg-Calve-Perthes disease

BACKGROUND

Most of the information available about Legg-Calve-Perthes disease (LCPD) at present is gained through imaging modalities including plain radiographs and magnetic resonance imaging (MRI). But the accuracy of MRI in this disease and its predictive value to reveal various intra-articular pathologies is not known. We correlated the findings of MRI with those seen on hip arthroscopy in children with active stage of LCPD.

METHODS

We conducted a prospective observational study in which MRI findings were correlated with corresponding findings on hip arthroscopy in a cohort of 25 patients of active LCPD below 12 years of age. The parameters noted on MRI included status of ligamentum teres, status of the labrum, synovial effusion if any, condition of the femoral and acetabular articular cartilage including chondral flaps, chondral indentation and intra-articular loose bodies. The indication of performing hip arthroscopy was persistent severe hip pain (Wong-Baker FACES pain scale ≥ 3) after 6 months of conservative management. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for MRI considering arthroscopy as a gold standard.

RESULTS

Synovial effusion was seen in a large number of patients on both MRI (17) and hip arthroscopy (24). The sensitivity (95% confidence interval) of MRI was found to be low, especially with respect to labral tears [25% (0.63-80.6)] and intra-articular loose bodies [20% (0.51-71.6)]. NPV for synovial effusion was also found to be low [12.5% (0.32-52.7)], although specificity and PPV of MRI were found to be good for all the parameters.

CONCLUSIONS

MRI cannot be completely relied upon for identifying all the intra-articular pathologies in children with LCPD, although it has a good complimentary role. In patients with severe persistent pain with suspicion for joint changes, hip arthroscopy can provide a safe and efficient procedure (better than MRI) for eliciting the associated joint pathology.

[Not Available]

Zusammenfassung. Radiuskopffrakturen sind zwar sehr häufige Verletzungen, heilen meist aber relativ schnell und unkompliziert aus. Mit dieser Häufigkeit und «Einfachheit» geht jedoch eine gewisse Bagatellisierung einher. Aber selbst bei den einfachsten Radiuskopffrakturen liegt in bis zu 18 % der Fälle eine Begleitverletzung der Weichteile vor. Werden diese übersehen und/oder nicht behandelt, können sie schwere Folgeschäden verursachen. In Anbetracht dieser Problematik sollte der klinische Verlauf bei diesen Patienten genau verfolgt werden. Ein Ausbleiben der Schmerzlinderung nach zwei Wochen konservativer Therapie sollte eine weitere Abklärung nach sich ziehen.

Osteochondrosis dissecans of the temporomandibular joint: a case report and a review of literature

A case of a 71-year-old female patient with osteochondrosis dissecans of the right temporomandibular joint is presented. Osteochondrosis dissecans usually occurs at the weight-bearing convex cartilage in all larger joints. It is rarely found in the temporomandibular joint and usually shows one or two loose bodies dislodged from defects which are present on the condylar head. Because of multiple loose bodies and a defect on the temporomandibular fossa, the case presented here is very uncommon.

Multiple Osseous Loose Bodies Associated with Lumbar Isthmic Spondylolisthesis

BACKGROUND

Multiple osseous loose bodies in the lumbar spine have never been reported. We describe a rare surgical case of multiple osseous loose bodies associated with lumbar isthmic spondylolisthesis.

CASE DESCRIPTION

A 74-year-old man who experienced left foot numbness and bilateral gluteal pain was diagnosed with lumbar spondylolisthesis 7 years previously and managed conservatively. He reported recurrence of the left foot numbness 6 months previously, at which time aggressive (rather than conservative) therapy became a consideration. Radiographs of the lumbar spine revealed L5 isthmic spondylolisthesis with dynamic instability at L5/S1. Magnetic resonance imaging of the lumbar spine revealed multiple mass lesions dorsally located in the lumbar canal. Computed tomography myelography demonstrated multiple osseous materials near the isthmic portion at the L5 level where compression of the dural sac by the lesions induced lumbar canal stenosis. The patient underwent posterior decompression surgery that enabled total removal of the osseous lesions. Intraoperative findings revealed osseous lesions located in the fibrocartilage material and no connection of the lytic portion at the L5 level or ligamentum flavum. Postoperative course of the patient was uneventful as his neurological symptoms improved.

CONCLUSIONS

We described the first instance of multiple loose bodies in the spinal canal with lumbar canal stenosis. It is presumed that long standing minor trauma due to dynamic instability with a trend of hyperossification induced secondary synovial osteochondromatosis forming multiple loose bodies.

Extra and Intra-articular Synovial Chondromatosis

Synovial chondromatosis is not so rare intra-articular condition secondary to synovial metaplasia, that affects the knee joint. Extra-articular synovial chondromatosis however is an extremely rare condition that usually involves the synovial sheath or bursa of the foot or hand. We present two cases of synovial chondromatosis, one intra and one extra-articular. The first case was a 25 year old lady who presented with pain, swelling and restricted range of motion of left knee and was found to have an intra-articular synovial chondromatosis which was treated successfully by joint debridement. The second case was that of a 22 year old man who presented with right knee pain and was diagnosed to have an extra-articular synovial chondromatosis of his right medial hamstring tendon sheath, excision of which resulted in complete relief of symptoms.

Synovial chondromatosis of the shoulder: open synovectomy and insertion of osteoarticular allogaft with internal fixation to repair intraoperative glenohumeral joint instability

Synovial chondromatosis is a rare benign disorder characterized by chondroid metaplasia with multinodular proliferation of the synovial lining of a diarthroidal joint, bursa, or tendon sheath. These cartilaginous nodules may become embedded within the proliferating synovium and may extend into the surrounding soft tissues. They also can detach from the synovium, where they can calcify and may present as intra-articular loose bodies. Presence of these nodules leads to joint pain, dysfunction, and ultimately, destruction. Clinically, patients often present with a chronic monoarthropathy. In this article, we report a case of extensive synovial chondromatosis of the right shoulder and surrounding soft tissues with extensive erosion of the humeral head, discuss combined anterior and posterior surgical excision of the cartilaginous fragments, and describe insertion of an osteoarticular allograft to repair the humeral head defect and secondary anterior glenohumeral joint instability.

Primary synovial osteochondromatosis in the ankle: a case report

Primary synovial osteochondromatosis results from the metaplasia of synovial tissue into cartilaginous tissue. This cartilaginous tissue then undergoes calcification and ossification, producing multiple osteochondral nodules. The cause of the metaplasia is unknown. Primary synovial osteochondromatosis is relatively rare and less common than secondary synovial osteochondromatosis. The primary form of the disease arises from the articular or tendon sheath synovium, whereas the secondary form is fragmented articular cartilage within the joint space. Primary synovial osteochondromatosis most commonly occurs in people aged 30 to 40 years and is more prevalent in men. Symptoms include pain, swelling, and decreased range of motion. Because of their abundance of synovial tissue, larger joints are more likely to be affected than smaller joints. Knees are the most commonly affected joints, followed by, in no specific order, shoulders, hips, and elbows. The ankle and the joints of the hand are seldomly involved. In the early stage of the disease, only active synovitis is present, and radiographs are negative. In the late stage, loose bodies can be detected on radiographs. Grossly, these bodies are consistent with ossified nodules. Microscopically, the nodules are composed of cartilaginous material lined by synovial tissue with a central area of calcification.

Synovial chondromatosis of the elbow causing a mechanical block to range of motion: a case report and review of the literature

We report a unique case of elbow synovial chondromatosis with sudden onset of severe loss of elbow extension and flexion range of motion caused by mechanical block from deposition of chondral fragments in the olecranon and coronoid fossae, respectively. We performed successful arthroscopic surgical treatment of synovial chondromatosis of the elbow. Arthroscopy examination revealed an acutely evolving synovial chondromatosis. Three-year follow-up indicated that arthroscopic removal of loose bodies and partial synovectomy can yield lasting improvement in motion without disease recurrence.

Arthroscopic loose body removal after hip fracture dislocation: experiences in 7 cases

OBJECTIVE

The aims of the present study were to describe the technique of hip arthroscopy for osteochondral loose body removal after posterior hip dislocation and report its preliminary results.

MATERIAL AND METHOD

We reported consecutive patients undergoing hip arthroscopy for osteochondral fragment after sustaining fracture-dislocations. Seven patients who sustained traumatic hip dislocation with incarcerated osteochondral were included in this study. All patients had standard AP pelvis x-rays and 3D-CT scans. After closed reduction, all patients underwent hip arthroscopy in which loose bodies were removed and labral pathology debrided.

RESULTS

The mean follow-up was 15.7 months. The average Harris Hip Score was 89.8. No patient developed any of the complications commonly associated with arthrotomy including avascular necrosis, heterotopic ossification, and nerve injury.

CONCLUSION

Arthroscopic treatment of intra-articular loose bodies after hip fracture-dislocations allows excellent visualization of the joint and facilitated straightforward removal of the fragment.

Osteochondrosis dissecans of the elbow

This case shows a typical presentation of an osteochondrosis dissecans lesion on the capitellum, with associated intra-articular loose bodie(s), diagnosed on plain film. Osteochondrosis dissecans (OCD) is a rather common entity. Mostly the knee joint is involved. Only 5% of OCD lesions occur in the elbow joint. Possible causes of osteochondrosis dissecans include (repetitive) trauma (e.g. in throwing sports or gymnastics), ischemia, ossification defects, and genetic factors. Conventional radiography mostly has a low sensitivity to detect OCD lesions, and is often normal in early stages. CT is more sensitive to detect intra-articular loose bodies. MRI detects very early stages of OCD and radiographically occult lesions that may not be evident on CT.

[Minimally invasive therapy of rheumatoid cubarthritis]

With the progression of rheumatoid arthritis more than half of the patients develop an affection of the elbow. Rheumatoid arthritis is the most common cause of elbow arthritis. The complexity of the rheumatic disease, which typically affects many joints, demands an individual therapeutic plan that can only be developed and accomplished successfully, when rheumatologists, rheumatoid surgeons and other specialists cooperate. Consistent use of approved and improved pharmaceuticals is abating the rate of rheumatoid cubarthritis. In cases of recurrent cubarthritis despite adequate medication, adverse reactions and other problems should be borne in mind before making a decision to change to more aggressive medication or synovectomy. Minimally invasive local measures, such as synoviorthesis and arthroscopic synovectomy can relieve pain and swelling, however, if lesions of the cartilage already exist, progressive joint destruction cannot be prevented. In early phases of rheumatoid cubarthritis with tight ligaments and thin synovial lining we prefer synoviothesis. In cases with recurrent cubarthritis after synoviorthesis or strong proliferation of the tunica synovialis, arthroscopic synovectomy is advantageous. Arthroscopic synovectomy is most effective in cases when there is ligament laxity in the sense of a late synovectomy, as removal of loose bodies, smoothening of the cartilage, release of the joint capsule and possibly arthroscopy-assisted resection of the radius head can be performed.

Outcome of 17 pigmented villonodular synovitis (PVNS) of the knee at 6 years mean follow-up

Between January 1950 and December 2000, 16 patients were identified from Scottish Bone Tumour Registry with 17 histologically proven pigmented villonodular synovitis (PVNS) of the knee. The mean follow-up was 6 years (range, 1-14 years). A knee swelling of chronic duration with dull ache was the common presenting symptom. The mean duration of symptoms prior to presentation was 25 months (1-108 months), however it was much less (mean, 7 months) in four patients with a history of trauma. The mean age was 33 years (range, 16-58 years) with a slight male predominance. The lesion was predominantly anterior in nine patients, posterior in four, anterolateral in two, and medial and lateral in one each. Three patients (four knees) had localised disease and 13 diffuse. Anteroposterior and lateral radiographs of the knee revealed normal findings in 11 patients, features of gonarthrosis in four and a large suprapatellar loose body in one patient (both knees). Open (incisional-eight, excisional-eight) biopsy was carried out in all and all were histologically confirmed as PVNS. Removal of a localised synovial mass or loose body with surrounding partial synovectomy (four) was carried out for the localised variety, whilst open partial (three) or total (radical) synovectomy (10) was performed in all cases of diffuse PVNS. Three of seventeen knees had a recurrence, noted at 4, 6 and 8 years postoperatively (0% - localised, 23% - diffuse variety). A total (radical) synovectomy should be considered in diffuse PVNS in order to obtain optimal outcome.

Synovial chondromatosis of four compartments of the knee: medial and lateral tibiofemoral spaces, patellofemoral joint and proximal tibiofibular joint

A case of synovial chondromatosis of the proximal tibiofibular joint in addition to lateral and medial tibiofemoral spaces and patellofemoral joint has been presented.

Temporomandibular joint osteochondritis dissecans: case report

BACKGROUND

Osteochondritis dissecans is a process in which segment(s) of cartilage separate from an articular surface. It is most often reported in the larger joints of the body, including the knee, elbow, hip, wrist, and ankle. Involvement of the temporomandibular joint (TMJ) is exceedingly rare.

OBJECTIVES

To describe a probable case of osteochondritis dissecans and discuss the differential diagnosis for this condition.

STUDY DESIGN

In addition to clinical examination the patient was imaged using panoramic radiography, computed tomography and magnetic resonance imaging.

RESULTS

Panoramic radiography showed separation of 2 rounded fragments superior to the right mandibular condyle. These were more precisely located using 3-dimensional computerized tomographic reconstructions. Magnetic resonance imaging demonstrated the right condyle as having low signal intensity area on T1-weighted images and a heterogeneous signal on T2-weighted images, with low signal dominance. No abnormality was apparent in the left TMJ.

CONCLUSIONS

The patient was treated nonsurgically with a splint, occlusal adjustment, physiotherapy, and nonsteroidal antiinflammatory medications. Maximum mouth opening has increased from 24 mm to 39 mm 6 months following initiation of treatment, and pain has subsided.

Magnetic resonance arthrography

For decades, fluoroscopic arthrography was the only method available to image a joint with contrast enhancement. Advances in CT led to the natural development of CT arthrography. Development of MRI and its capability for multiplanar imaging led to direct magnetic resonance arthrography (MRA). This technique has been performed since 1987 and has surpassed CT arthrography in popularity in the United States. Indirect MRA developed subsequently to offer a less invasive alternative. This article presents an overview of direct MRA and addresses joint-specific issues regarding direct MRA. An overview of indirect MRA also is provided.

Posterior Malleolar Fracture is Often Associated with Spiral Tibial Diaphyseal Fracture: A Retrospective Study

BACKGROUND

It is known that posterior malleolar fracture is often associated with tibial diaphyseal fractures. However, in literature there are very few studies on tibial shaft fractures with respect to posterior malleolus fragment. We hypothesized that the incidence of posterior malleolar fracture is higher than in previous studies.

METHODS

A total of 74 closed tibial shaft fractures were treated with intramedullary nailing in Turku University Central Hospital between January 1994 and December 1998. There were 55 men and 19 women, with a mean age of 39 years (range, 16 to 58 years). Two cases were excluded and 72 tibial shaft fractures were analyzed retrospectively.

RESULTS

Posterior malleolar fracture was observed in 18 cases (25.0%). Only 10 were observed preoperatively in plain films, seven were detected postoperatively and one was not detected at all during the treatment. Retrospectively, all 18 posterior malleolar fractures were detectable in preoperative plain films.

CONCLUSION

A fracture of the posterior malleolus was involved in every fourth tibial diaphyseal fracture. The fractures of the posterior malleolus were always detected in preoperative plain films and should be suspected, especially in cases of low-energy spiral distal tibial diaphyseal fractures. We recommend additional plain films to be taken at the ankle region to better visualize these fractures.

Hip arthroscopy to remove loose bodies after traumatic dislocation

OBJECTIVES

This study was designed to review the incidence of arthroscopically detected intra-articular loose bodies found in patients after traumatic hip dislocation or small acetabular wall fracture which would not otherwise be treated without surgery.

DESIGN

Retrospective review.

SETTING

Level 1 academic trauma center.

PATIENTS

Thirty-six patients who sustained traumatic hip injuries and subsequently had 39 hip arthroscopies between November 1997 and January 2004 were reviewed.

INTERVENTION

All patients had standard AP pelvis x-rays and CT scans performed. At our institution, patients with hip dislocations or acetabular wall fractures not otherwise requiring surgery are routinely offered hip arthroscopy to remove loose bodies. The radiographs were reviewed to determine incidence of loose bodies or nonconcentric reduction before hip arthroscopy. Chart review provided incidence of loose bodies found during arthroscopy.

MAIN OUTCOME MEASUREMENTS

Comparison was made between radiographic data obtained preoperatively and operative findings.

RESULTS

Loose bodies were found in the hips of 33 of 36 patients (92%) who were arthroscoped. Loose bodies were found in 7 of 9 cases (78%) in which standard radiographic studies (AP pelvis x-rays and CT scan) found no loose bodies and a concentric reduction.

CONCLUSIONS

Loose bodies are routinely present after closed treatment of hip dislocations or wall fractures not otherwise requiring surgery, even when radiographs are negative. Hip arthroscopy may be indicated for loose body removal when open treatment is not otherwise necessary.

[Arthroscopic treatment of symptomatic loose bodies in osteoarthritic elbows]

OBJECTIVES

We evaluated functional and clinical results of patients who underwent arthroscopic surgery for symptomatic loose bodies in osteoarthritic elbow joint.

METHODS

Arthroscopic surgery was performed in 10 patients (6 males, 4 females; mean age 47 years; range 30 to 59 years) for symptomatic loose bodies in osteoarthritic elbow joint. Eight patients had a history of trauma. Involvement was on the right in seven patients, and on the left in three patients. Preoperatively, six patients had limited joint movements and locking, and five patients had pain. The presence and the number of loose bodies were investigated by standard radiographs and computed tomography preoperatively, and by radiographs and magnetic resonance imaging postoperatively. The range of motion was measured with a goniometer. Functional assessment was made with the use of the Broberg and Morrey's scoring system, and pain was assessed with a visual analog scale. The mean follow-up was 31 months (range 7-59 months).

RESULTS

The mean range of motion of the elbows increased from 100 degrees (range 55 degrees to 160 degrees) preoperatively to 115 degrees (range 70 degrees to 160 degrees) at the end of the follow-up (p=0.05). None of the patients developed valgus or varus instability. The mean preoperative and postoperative Broberg and Morrey's scores were 59 (range 45 to 80) and 86 (range 59 to 100), respectively (p<0.01). The results were excellent in five patients, good in three patients, and poor in two patients. The mean visual analog score decreased from 7 (range 5 to 10) preoperatively to 1 (range 0-4) postoperatively (p<0.01). Eight patients were satisfied with surgery and returned to normal activities after a mean of 16 days (range 1 to 60 days).

CONCLUSION

Arthroscopic surgery is effective in reducing pain in selected patients with symptomatic loose bodies in osteoarthritic elbows, with the advantages of low morbidity and rapid functional recovery.

Arthroscopic surgery to treat intra-articular type snapping hip

PURPOSE

To reveal the causes of the intra-articular type snapping hip and their frequency.

TYPE OF STUDY

Case series.

METHODS

We studied 2 hip joints of 2 male patients and 30 hip joints of 28 female patients with snapping hip syndrome, in which the accompanying pain was transiently relieved by intra-articular injection of local anesthetic. The mean age at diagnosis was 26 years. Plain radiography, hip arthrography, magnetic resonance imaging (MRI), and arthroscopy were performed in these patients and the findings were compared.

RESULTS

Plain radiography findings showed no abnormality in 11 joints, hip osteoarthritis in 19 joints, and femoral head deformation caused by Perthes disease and synovial osteochondromatosis in 1 joint each. Excluding the case of synovial osteochondromatosis, 31 joints were examined by MRI, which failed to identify the cause of snapping hip in all cases. Hip arthrography revealed an intra-articular loose body in 2 joints with osteoarthritis. Arthroscopy revealed acetabular labral tears in all 11 joints with no abnormalities and 15 of 19 joints with osteoarthritis on plain radiography films, and incompatibility between acetabular labrum and deformed femoral head in 2 joints with osteoarthritis. In the case of femoral head deformation after Perthes disease, arthroscopy revealed detachment of the femoral head cartilage as a result of impingement of the acetabulum on the femoral head. Arthroscopic surgeries were conducted: partial limbectomy for acetabular labral tears, surgical removal of loose bodies, partial femoral head excision for incompatibility between acetabular labrum and deformed femoral head, and shaving or articular cartilage detachment. The surgeries resolved the snapping in all cases.

CONCLUSIONS

Acetabular labral tear was the cause of 80% of cases of intra-articular type snapping hip. Incompatibility between the acetabular labrum and a deformed femoral head was found to be a cause of intra-articular type snapping hip.

LEVEL OF EVIDENCE

Level IV, case series.

Calcified loose bodies trapped in the lateral synovial recess of the knee

Calcified loose bodies originate in the knee joint for a variety of reasons and are removed when symptomatic. We present the case of a 56-year-old man who had multiple calcified bodies located in a sac beneath the iliotibial band known as the lateral synovial recess of the knee. Despite the fact that these loose bodies likely arose from the joint, they were unable to be visualized during arthroscopy and required a separate lateral incision for removal.

Radiography of the elbow for evaluation of patients with osteochondritis dissecans of the capitellum

OBJECTIVE

This study was performed to determine the ability of a routine radiographic examination of the elbow to detect osteochondritis dissecans of the capitellum and associated intra-articular loose bodies.

DESIGN AND PATIENTS

The study group consisted of 15 patients with osteochondritis dissecans of the capitellum confirmed by surgery or magnetic resonance imaging. Seven of the 15 patients had associated intra-articular loose bodies confirmed by surgery. All 15 patients had anteroposterior and lateral radiographs and magnetic resonance imaging of their symptomatic elbow. Nine of the 15 patients had subsequent elbow surgery. We reviewed the original interpretations of the radiographic examinations of the elbow of all 15 patients to determine whether osteochondritis dissecans of the capitellum and associated intra-articular loose bodies had been identified prospectively. We also reviewed the elbow radiographs of all 15 patients to determine whether osteochondritis dissecans of the capitellum and associated intra-articular loose bodies could be identified retrospectively.

RESULTS

Osteochondritis dissecans of the capitellum was detected during the initial interpretations of the radiographic examinations of the elbow in seven of 15 patients. Osteochondritis dissecans of the capitellum was detected during retrospective review of the elbow radiographs in 10 of 15 patients. Intra-articular loose bodies were detected during the initial interpretations of the radiographic examinations of the elbow in three of seven patients. Intra-articular loose bodies were detected during retrospective review of the elbow radiographs in four of seven patients.

CONCLUSIONS

A routine radiographic examination of the elbow has limited sensitivity for detecting osteochondritis dissecans of the capitellum and associated intra-articular loose bodies.

Synovial chondromatosis of the temporomandibular joint: a clinical, radiological and histological study

Synovial chondromatosis (SC) is a cartilaginous metaplasy of the mesenchymal remnants of the synovial tissue of the joints. It is characterized by the formation of cartilaginous nodules in the synovium and inside the articular space (loose bodies). SC mainly affects to big synovial joints such as the knee and the elbow, being uncommon the onset within the TMJ, where 75 cases have been published. The main symptoms are pain, inflammation, limitation of the movements of the jaw and crepitation. Different methods of diagnosis include panoramic radiograph, CT, MR and arthroscopy of the TMJ. We report a new case of unilateral SC of the TMJ, including diagnostic images, treatment performed and histological analysis.

Belastungs- oder lageabh�ngige Schwellung der Wadenmuskulatur mit Spannungsgef�hl und krampfartigen Schmerzen

Popliteal vein entrapment must be taken in consideration in patients with symptoms of venous insufficiency. Leg edema, swelling, calf pain, and muscle cramps are all unspecific signs. Most patients thus far have presented with deep vein thrombosis or chronic venous insufficiency. Popliteal entrapment syndrome must be taken into account in younger patients in whom predisposing factors are absent and chronic calf swelling is notable. Diagnosis is easily confirmed by noninvasive stress testing with duplex imaging and pencil Doppler probe placed over the posterior tibial artery. Additionally, digital subtraction angiography with the foot in neutral and dorsi plantarflexion is recommended for arterial entrapment. Surgery is advisable for treatment and can be done without significant morbidity. In asymptomatic patients, we suggest using the term "popliteal vein entrapment phenomenon." We describe different etiologies of popliteal vein entrapment in three cases and present a review of the literature.

Aneurysma spurium und verz�gerte Blutungskomplikation durch ein sekund�r disloziertes Trochanter-minor-Fragment bei pertrochant�rer Femurfraktur

A 92-year-old woman incurred an unstable pertrochanteric hip fracture with avulsion of the lesser trochanter (type 31-A2 according to the AO classification). The fracture was treated by gliding nail osteosynthesis, without fixing the minimally displaced lesser trochanter. No intra- or postoperative complications were detected. Suddenly, after 30 days, a swelling of the proximal femoral region, accompanied by signs of haemorrhage, occurred.CT-scans showed a false aneurysm of the deep femoral artery and a dorsal laceration of the artery proximal to the aneurysm. X-rays showed a further dislocation with rotation of the lesser trochanter fragment. Intraoperatively, the tip of the lesser trochanter fragment was identified to be responsible for the laceration of the artery. The false aneurysm was resected and the defect bridged by a vascular prosthesis while the fragment was removed. Follow-up showed no further complications. According to case reports from the literature, false aneurysms and laceration of the deep femoral artery caused by dislocated lesser trochanter fracture fragments are rare.

Multiple rice body formation in the subacromial-subdeltoid bursa and knee joint

Multiple rice body formation is an uncommon disorder which resembles synovial chondromatosis both radiologically and clinically. The clinical symptoms are usually non-specific. We report on a pathologically proven multiple rice body formation in both the left subacromial-subdeltoid bursa and knee joint in a 4-year-old girl.

[Osteotomy of the iliac fossa in the treatment of a hip dislocation associated with a two-column acetabular fracture. Modification of the ilioinguinal approach to avoid an extended surgical approach]

Open reduction and internal fixation is the treatment of choice for displaced acetabular fractures. The surgical approach depends on the fracture type, concomitant injuries, and general condition of the patient. The ilioinguinal approach provides a good exposure to the medial wall and is associated with an acceptable degree of surgical trauma. Exposure of the joint surface, however, is difficult when using the ilioinguinal approach. We report a case of a polytraumatized 39-year-old patient who sustained a posterior hip displacement and a two-column acetabular fracture. An osteotomy of the iliac ala was performed via an ilioinguinal approach to fragments of the acetabular surface that were displaced distally. Thereby, reposition of a craniolateral fragment was achieved without the need to extend the surgical approach or to perform a second incision.

Recurrence of synovial chondromatosis of the glenohumeral joint after arthroscopic treatment

A case of primary synovial chondromatosis of the shoulder in a 15-year-old girl is presented. Plain radiographs revealed findings characteristic of synovial chondromatosis. The patient was treated by arthroscopic loose body removal and arthroscopic partial synovectomy of the glenohumeral joint. Although immediate postoperative radiographs showed no calcification in the joint, repeated radiographs at 18 months after surgery revealed recurrence of calcification in the subacromial space. Arthroscopic removal of all loose bodies and partial synovectomy appears to be a good method of giving symptomatic relief and early return to work. However, late recurrence should be anticipated.

CT features of synovial chondromatosis in the temporomandibular joint

OBJECTIVE

The purpose of this study was to determine the characteristic computed tomography (CT) findings of synovial chondromatosis of the temporomandibular joint (TMJ).

STUDY DESIGN

Eight subjects with synovial chondromatosis were examined with axial and coronal CT scans. All lesions were histopathologically confirmed either through an arthroscopic punch biopsy or surgery. CT appearances of the lesions were reviewed and classified.

RESULTS

Among the 8 subjects, 7 (87.5%) demonstrated soft tissue swelling, 7 (87.5%) showed loose calcified bodies, and 6 (75%) had bony changes of the articular surfaces. Patterns of the skull base changes as well as intracranial extension of the disease were identified.

CONCLUSIONS

Based on the CT findings, synovial chondromatosis of the TMJ is characterized by soft tissue swelling, loose calcified bodies, and bony changes of the skull base. The latter may lead to destruction of the central skull base and intracranial extension.

Irreducible palmar dislocation of the proximal interphalangeal joint caused by a fracture fragment: a case report

We present a case of irreducible palmar dislocation of the proximal interphalangeal joint of the little finger caused by entrapment of a fracture fragment attached to the collateral ligament. The bony fragment was trapped between the radial condyle of the proximal phalanx and the volar plate. Reduction was easily accomplished by hooking out the fragment.

Loose body in the wrist: diagnosis and treatment

PURPOSE

The purpose of this study was to report on 10 cases of symptomatic loose bodies in the wrist joints diagnosed using arthroscopy.

TYPE OF STUDY

Retrospective review.

METHODS

From 1986 to 2000, we performed wrist arthroscopy for 707 patients, 10 of whom had loose bodies in the wrist joints. The clinical records were reviewed retrospectively. The patients included 8 men and 2 women, and the average age was 28 years (range, 16 to 67 years). The chief complaint was wrist pain in all patients, but locking was uncommon. Preoperative diagnosis was difficult in all but 3 cases; in those cases, an osseous component was found within the loose bodies. The remaining cases were diagnosed by wrist arthroscopy.

RESULTS

The loose bodies existed in the radiocarpal joint in 5 cases, and all could be removed arthroscopically. In the other 5 cases, the loose bodies were in the distal radioulnar joint, and arthrotomy was needed to remove them. After removal of the loose bodies, the pain was relieved in all cases without any surgical complications.

CONCLUSIONS

Loose bodies in the wrist joint should be included in the differential diagnosis for chronic wrist pain. Wrist arthroscopy is of value because the preoperative diagnosis is usually difficult.

Hip arthroscopy for osteochondral loose body removal after a posterior hip dislocation

We report on the application of hip arthroscopy to remove an osteochondral fragment created by a posterior hip dislocation. Preoperative and postoperative radiographs and computed tomography scans correlate with intraoperative arthroscopic photographs and are presented with this report. Arthroscopy allowed excellent visualization of the joint and facilitated straightforward removal of the fragment. We were able to avoid the larger incision required by an arthrotomy and decreased the patient's overall morbidity from this condition.

Arthroscopic removal of a loose body osteophyte fragment after superior patellar dislocation with locked osteophytes

The authors report the case of a loose body from a fractured osteophyte after a superiorly dislocated patella with locked osteophytes. Few cases of superiorly dislocated patellae have been reported in the literature and no cases of osteophyte fracture fragments after locked osteophytes with subsequent arthroscopic loose body removal have been reported. The loose body was removed and the distal pole of the patella was debrided arthroscopically. This patient and the majority of previously reported cases, herein reviewed, had patella alta with pre-existing patellofemoral arthrosis. Patella alta in the face of patellofemoral arthrosis should be considered a risk factor for loose body formation. Therefore, recurrent superior patellar dislocation and locking osteophytes may be a relative indication for pre-emptive arthroscopic debridement of locked osteophytes.

[Apparent pseudarthrosis of the thumb]

Pseudarthrosis in the hand are defined as a non-union of a fracture after 6 month. Reasons might be biological disorders, mechanical instability or infection after fracture treatment. Pseudoarthrotic bone demands stable osteosynthesis and often bone grafting. The presented case is about a dislocated osseous fragment attached to the Aponeurosis dorsalis mimicking clinical and radiological a Pseudarthrosis of the proximal phalanx of the thumb. We would like to draw attention that osseous fragments may present very similarly to a pseudoarthrosis of a phalanx.

Fate of the osteochondral fragments in osteochondritis dissecans after Legg-Calve-Perthes' disease

The treatment of osteochondritis dissecans after Legg-Calvé-Perthes' disease has not been clearly determined. It may be either by simple observation or surgical removal of the osteochondral fragment. We studied the evolution of the lesion in 13 children and reviewed 92 hips reported in the literature. In our patients ten showed a tendency towards spontaneous healing, one required drilling + grafting to obtain fusion, and in two there was separation into the joint. These loose bodies were in the acetabular fossa and caused no symptoms. On reviewing the literature, we found only four cases of hips with loose bodies from osteochondritis dissecans. These were lying in the inferomedial capsule and were also asymptomatic. Treatment of osteochondritis dissecans after Legg-Calvé-Perthes' disease should therefore be conservative unless the fragment interferes with the mechanics of the hip.

[Ultrasound examination technique of the elbow and wrist joints]

Ultrasound examination of the elbow and hand is invaluable in diagnostics of acute and chronic joint diseases. Ultrasound is a noninvasive, immediately available procedure without radiation, which should be performed after exploration and clinical examination. It cannot, however, replace radiographic examination because the cortical substance represents a barrier for the ultrasound waves so that bony lesions (i.e., intraosseous tumors or osteomyelitis) cannot be detected. In the diagnosis of periarticular soft tissue lesions and intra-articular changes (loose bodies, intra-articular effusion, or synovitis), ultrasound represents an excellent cost-effective method supplying additional information. The sonographic technique is presented with the standard sectional planes according to the directives given by the working group on the musculoskeletal system of the German Society for Ultrasound in Medicine (DEGUM) issued on 20 January 1996.

A 2-staged method for treatment of deep osteochondral lesions of the knee joint

We performed a 2-staged arthroscopic-assisted surgical procedure to treat a patient with a large osteochondral lesion of the knee joint. The osteochondral lesion was too comminuted to reattach; in addition, the underlying bony defect was too deep. In the first stage, autogenous cortical bone was used for grafting the bony defect along with screw fixation. The second stage consisted of screw removal and transplantation of autogenous osteochondral graft overlying the chondral defect. The osteochondral grafts were taken from the non-weight bearing areas of the same knee.

Ultrasound of the elbow

This article describes the use of ultrasound (US) in the evaluation of the elbow. US is able to visualize several abnormalities affecting tendons, muscles, ligaments and bursae around the elbow joint as well as to delineate the nature of soft-tissue swelling, such as a space-occupying lesion or synovial enlargement. Occult fractures, osteophytes and intra-articular loose bodies can be depicted with this technique as well. At the cubital tunnel, US allows accurate imaging of the ulnar nerve and to document changes that occur in compressive syndromes. Over other imaging modalities, US offers several key advantages, including cost effectiveness, availability and ability to perform a dynamic examination of tendon movement and joint motion. With continued experience, it is likely that the use of US will increase further with regards to evaluation of soft-tissue abnormalities of the elbow.

Incidence of loose bodies in an osteoarthritic hip

In a prospective study of 75 consecutive primary Charnley low friction arthroplasties carried out for osteoarthritis, loose bodies were found in nine hip joints; an incidence of 12%. Whether their presence is the cause or the effect of the condition remains unclear. Their discoid or spherical shape suggests that they were free and had been subjected to sliding or rolling motion. Those of irregular shape may have remained partly attached within the capsule, or become confined to a space.