Miscellaneous Problems: Synovitis, Degenerative Joint Disease, and Tumors

CHAPTER 6 Miscellaneous Problems: Synovitis, Degenerative Joint Disease, and Tumors



Synovitis of the hip has many causes. In this chapter, we will discuss only five of the pathologic entities causing primary synovitis—rheumatoid arthritis (RA), calcium pyrophosphate dihydrate crystal deposition disease (CPPD), fatty deposition disease (hyperlipoproteinemia), hemachromatosis, and pyarthrosis—and their arthroscopic treatment.

The role of arthroscopic synovectomy in treating synovial diseases was apparent to the earliest arthroscopists. In almost all pathology of the hip, synovitis is present. Our group has had several undiagnosed cases of hip pain with effusions that were shown to be seronegative rheumatoid arthritis with synovial biopsy. In 1988, Ide and colleagues1 performed arthroscopic synovectomy for RA on six hips in three patients using mechanical shavers through a two-portal technique, with good results. With the advent of laser and radiofrequency (RF) ablation, there are now three modalities used to débride the synovium. It remains difficult to reach 100% of the joint but with newer, more effective medical management, debulking of the diseased synovium seems to be adequate.

CPPD has not been reported as frequently in the hip as it has in the ligamentum flavum and in the knee, associated with RA.2,3 Our group has performed synovectomy on two patients for CPPD associated with femoroacetabular impingement. Clearly, it is an entity that should be considered in the differential diagnosis of patients with refractory synovitis.

There are no reports in the arthroscopic literature on the treatment of hyperlipoproteinemia, hemachromatosis, or any of the metabolic arthropathies. Our group has performed partial synovectomy in a few patients thought to have fatty deposition and in one patient with hemachromatosis associated with arthritis. It is presented here only to make the arthroscopic surgeon aware that metabolic arthropathies exist.4 Metabolic arthropathy appears as white or yellowish plaques on the articular cartilage associated with a mild synovitic reaction. The plaque cannot be removed without destroying the articular cartilage and therefore should be treated with synovectomy only.

Arthroscopic débridement and lavage has become the treatment of choice for septic arthritis in children, adolescents, and adults. This modality has been associated with minimal morbidity and an excellent cure rate.58 McCarthy and associates9 have reported on successful treatment of septic total hips in two patients using arthroscopic débridement, lavage, and intravenous antibiotics Our group has successfully treated four patients with late hematogenous infections of their total hips arthroscopically. No recurrence has been noted, with the longest follow-up being 20 years, when one patient died from natural causes at the age of 93 years (Fig. 6-1).


Essentially all tumors that are amenable to arthroscopic treatment are benign. Pigmented villonodular synovitis (PVNS) and synovial chondromatosis may be considered synovial diseases instead of tumors, and are both difficult to eradicate unless a complete synovectomy can be performed. Frequent recurrences are seen, from inadequate removal of the tumors or inadequate synovectomy.1517 Capsulotomy is recommended to expose all areas and recesses of the central and peripheral compartments to remove the loose and attached bodies and ablate the synovium, particularly where the lesions are forming.

Arthroscopic removal of osteoid osteoma of the hip has been described by Glick and colleagues18 in two cases in the central compartment. Our group has since removed an old, yet active osteoid osteoma from the head-neck junction associated with a cam impingement requiring excision, synovectomy, and head neck osteoplasty (Fig. 6-2).

Heterotopic bone should be considered a pseudotumor of the hip and is most often a complication of trauma or hip surgery. There are no reports of its treatment using arthroscopic techniques; however, our group favors arthroscopic excision and follow surgery with a single dose of 700 rad of radiation or a strong dose of nonsteroidal anti-inflammatory drugs (NSAIDs) for 3 to 6 weeks. The recurrence rate is lower with the subsequent radiation.


Synovitis of the hip may present with pain in the groin, buttock, and trochanter. The hallmarks of the presentation and examination are associated with an irritable hip. Much like an acute abdomen that is stiff and exquisitely painful on palpation and jarring, the irritable hip is very painful on palpation and rotational movements. Synovitic hips will have pain with all ranges of motion or at the extremes of motion when tested passively. Septic hips may vary as to the level of pain, depending on the organism type and the tenseness of the effusion.

Degenerative joint disease presents with or without a limp, and difficulty walking, sitting, and putting on shoes and socks because of restricted range of motion. With the loss of articular cartilage, a straight leg raise with the knee extended may cause pain in the groin because of the compressive forces of the opposing chondromalacic surfaces of the head and acetabulum. There may be popping and catching with rotation. Loss of internal rotation is almost always present. The Trendelenburg sign and test may be negative in milder cases. Our group has found that if there is at least 50% range of rotational movement when tested passively compared with the normal contralateral side, and if more than 50% of articular cartilage thickness on the anteroposterior (AP) x-ray is present, results show a more than 80% chance of significant improvement that continues for more than 2 years (Fig. 6-3).

Tumors present with pain and, in many cases, popping and catching. There may be a limp if there is an effusion. Range of motion may be restricted if catching or locking is present. Most patients may present with entirely normal movement. Osteoid osteomas usually cause night pain that is relieved by aspirin or other NSAIDs.18,19

Jun 19, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Miscellaneous Problems: Synovitis, Degenerative Joint Disease, and Tumors

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